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If you’ve just received notice that you are being audited or investigated, it isn’t a time to worry. While audits and investigations can have serious consequences depending on what is discovered, you will want to ensure you’re taking all the right measures during the audit or investigation to put yourself out on top.
But in order to successfully make it through an audit or an investigation, you need to understand what it means.
An audit and an investigation are not the same. While they both call for a legal examination of your spending or billing, they are actually stimulated in completely different ways.
If you are under audit, it means that someone – typically an insurance provider or contractor – has identified a red flag that they would like to look into. These red flags may include things like overspending on medical equipment or overcharging on services and treatments. An audit may also be triggered if you are charging for treatments or procedures outside of what is expected for a patient’s condition. Audits may also be triggered randomly in an effort to control healthcare spending.
When an audit is triggered, it does not necessarily assume that fraud or illegal activity is present. Instead, an audit is asking for more information or an explanation behind why something was charged or why the price is so high.
If you’re under audit, you will want to provide the best defense possible for your charges and actions. This usually includes the assistance of a San Antonio Healthcare Audits Investigations Lawyer.
Because the organization auditing you is looking to save themselves money, they will look for any instance or mistake to show that you are overcharging. This may mean scrutinizing every comment you make or ignoring your defenses. If you have a Healthcare Audits Investigations Lawyer working with you, you can create a stronger defense for your case.
If the audit finds fraudulent behavior, it may then change into an investigation.
A healthcare investigation differs from a healthcare audit in what information the reviewers are searching for. Unlike an audit, a healthcare investigation is looking for illegal activity or proof that you have been dishonest in your billing or purchasing.
While an audit is asking you to defend your purchases and provide an explanation, an investigation wants to find evidence or proof that you have been acting illegally. An investigation is done by a law enforcement agency.
A healthcare investigation may begin if law enforcement gets word that you are potentially engaging in fraudulent or illegal activity. This activity may be discovered through an audit or suspicious billing patterns may trigger an investigation. It is also not uncommon to have employees of the medical practice provide a tip to law enforcement that billing may not be correct.
The ultimate outcome for an investigation is also different than an audit. In many ways, an audit is done to save one company money. If an insurance provider requests an audit, they are hoping to find an area that can put some cash back in their pocket. But because an investigation is looking for illegal activity, the ultimate end goal is to find evidence to take away licenses of responsible professionals and potentially punish them with criminal prosecution.
Depending on what investigators find, you may face jail time or steep fines because of a healthcare investigation. An investigation can also be damaging to the practice’s reputation, even if the claim proves to be untrue.
In order to effectively control and prepare for an investigation, you will want to contact a San Antonio Healthcare Audits Investigations Lawyer as soon as you know that an investigation is happening. With the help of an expert attorney, you can develop a clear understanding of possible consequences and what you will need to do to avoid them. Your attorney will work with you to develop a defense or to negotiate a shorter and less severe sentence.
Whether you’re being audited or investigated, you shouldn’t attempt to go through the process alone. A San Antonio Healthcare Audits Investigations Lawyer can guide you through the process and secure the best possible outcome for you and your practice.