Audits and Investigations
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.
We provide assistance in the following areas:
- Medicare/Medicaid audit defense
- Tricare audit defense
- Recovery Audit Contractor (RAC) audit defense
- Zone Program Integrity Contractor (ZPIC) audit defense