State and federal governments are working to crack down on the overpayments issued to medical facilities each year as they exceed a billion dollars annually. Medicaid and Medicare are government issued healthcare programs that fund the affordability of healthcare for those with low-incomes, the disabled, and the elderly. These programs are designed to offer support to those who require medical attention, but they’re costing taxpayers and the government substantially each year. To eliminate the vast overpayments issued annually, insurance companies and the government solicit the help of healthcare auditors and investigators.
Any healthcare facility can be audited or investigation. Some are chosen at random, and others are chosen for an audit based on red flags and potential overpayment that’s noticed by the payer. The process begins with an audit, and only results in an investigation when an office is suspected of committed fraud. If your office is being audited, it’s not a reason to worry. It’s still a good idea to call a healthcare auditor and investigation attorney who specializes in this type of medical law.
The Audit Process
Unless chosen randomly, a medical facility is not audited for overpayment issues unless there is a red flag appearing in one or more locations throughout the payment process.
– Many patients are being charged for the same procedure. This is a massive red flag for auditors as it means one doctor’s office is charging multiple patients for the same type of care. Since most people have different health needs, it’s sometimes a red flag when dozens of patients seem to suffer from the same issues requiring the same expensive testing or procedures. Of course, this happens often at offices with a specialty focus, or when there is an outbreak of a specific illness or disease in a specific city.
– Duplicate bills are paid for the same patient for the same appointment. This occurs from time to time due to administrative error. If two people in the same office submit the same paperwork to insurance companies by mistake, duplicate bills are issued. It’s not fraudulent to make mistakes, and most of these issues are very easily handled.
– Many patients are being given multiple tests and procedures at every appointment. When you have one patient who comes into the office for one issue and ends up having multiple tests done, it’s not an issue. When dozens of patients come in for a simple cold and end up leaving with thousands of dollars in procedures noted, it’s suspicious.
Most overpayments are mistakes, and they’re easily corrected. Medical facilities needn’t worry they are in trouble with the federal government because a clerical error resulted in an incorrect bill. However, some audits show a significant presence of mistakes, and it makes an investigation necessary.
When a doctor’s office is unable to prove their overpayment mistakes were just mistakes or there are so many mistakes it looks suspicious, an investigation is opened by the federal government. This requires the office to comply with the requests of the government, and it usually results in bad news for the physician in charge. If found guilty of fraud, the physician faces the following punishments.
– Fines – Most fines are not to exceed $5,000 per count.
– Restitution – If a doctor is guilty of stealing money by falsifying records, incorrectly charging patients, or overcharging insurance companies, they’re required to pay back every penny they took.
– Prison Time – Fraud is a federal criminal offense, and each count is worth up to five years in prison.
– Loss of a Medical License – When a doctor is accused of fraud and tried in a court of law, they obtain a criminal record. No doctor with a criminal record is able to continue practicing, so their license is revoked permanently with no chance of reinstatement.
It’s always a good idea to turn to an attorney with ample legal experience in this type of case. Even if an attorney can’t turn a guilty client into an innocent one, they can work to have charges reduced following settlement hearings and other forms of discipline. Attorneys can also help medical facilities avoid further chance of auditors showing up by helping with billing laws and legal expertise.
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If you are a health care provider, then it’s essential you take proactive steps to keep your financial records as accurate as possible so that you don’t need to worry about the outcome of an audit. Staying safe means always using caution when you bill an insurance company so that you don’t get accused of overcharging. Getting audited does not always mean you will face negative consequences, but it can still be a stressful experience. Staying updated on related laws can go a long way to help keep you and your practice safe, but you cannot eliminate the odds of being audited entirely. It’s important you learn about the auditing process before you find yourself in the middle of it. Learning how to respond to an audit can be the difference between having the charges dropped and facing time in prison.
In some cases, insurance companies randomly adult health care providers so that they can spot instances of overpayment that might not be apparent right away, and you can do nothing to prevent this from happening. You will also be audited if you set off any red flags during the course of your job. For example, if an insurance company feels as though you have been overcharging for a service, they will take action to determine whether the related claims are legitimate.
Auditors will pay close attention to detail so that they can determine the accuracy of each record. During this time, they will check each claim to ensure it matches a corresponding patient record so that they can verify its legitimacy. If they find any discrepancies, their next step is to determine whether you made a mistake or tried to commit fraud.
If a health care auditor determines you have overcharged the insurance company on purpose, then they will likely turn the situation over to a federal law enforcement agency. Rather than searching for mistakes, federal agents will now be looking for evidence of fraud and other criminal activity. If the federal agents do not find enough evidence to use against you, then they will drop the case, and you will not face charges. However, if they determine sufficient evidence is present, then you will be subject to prosecution and civil litigation. No matter the outcome, if an investigation gets this far, your career will be placed in jeopardy.
Responding to an Audit
When a health care auditor first decides to check your records, you are not likely to be notified. They don’t want you to take steps to protect yourself until they have enough evidence to use against you. It’s important you remember that evidence of an overcharge does not always result in criminal charges. But if the auditors believe you made a mistake, they will still expect you to pay back the amount you owe. Either way, they plan to take action by the time you realize they are auditing you. So, it’s vital you contact a lawyer right away so that you can have the best possible odds of winning your case. If an auditor tries to ask you questions, do not respond until you have spoken to a legal adviser. Otherwise, anything you say will likely be used as evidence against you, damaging the durability of your case.
Although being audited is a stressful experience, you do not need to feel powerless to protect yourself. The first step you must take to stay safe is to ensure all of your records are accurate. It’s also vital you use caution when entering a patient’s billing information so that your motives don’t get called into question by investigators. By the time an insurance company notifies you that an audit has taken place, the odds are already stacked against you. At best, you will be forced to repay any questionable claims. In the worst case, you will be put on trial for fraud, and you could find yourself in prison if your case goes downhill. If you want to stay safe from legal problems, then you must contact a lawyer the second you realize you are being audited or investigated so that you can build a strong defense.
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