Cigna Audit Defense Attorneys
Our Healthcare Defense Lawyers Represent Providers Nationwide in Cigna Healthcare Audits
Healthcare providers that bill Cigna are subject to the company’s auditing requirements, processes, and procedures. Cigna has a Corporate Audit Department that is responsible for ensuring providers’ compliance with the company’s rules and requirements (as well as the requirements of Medicare and other payors), and the Corporate Audit Department’s Special Investigations (SI) team works to “identify suspicious claims, stop payments to fraudulent providers and punish wrongdoers.”
As Cigna also notes, “The SI team also works with state and federal law enforcement and regulatory agencies and other insurance companies to detect, prevent and prosecute health care fraud. The SI team includes trained professionals with expertise in investigations, health care, nursing, law enforcement and accounting.” Thus, the risks of facing a Cigna audit can extend far beyond recoupment liability and prepayment review (which themselves can have substantial financial implications for participating providers). With this in mind, providers that are facing Cigna audits need to take these audits very seriously, and they need to assert an effective defense with the help of experienced legal counsel.
10 Important Facts about Facing a Cigna Healthcare Audit
At Oberheiden P.C., our healthcare defense lawyers bring relevant experience to representing providers during Cigna healthcare audits. We have significant experience handling audits conducted by Aetna, United Healthcare, and other companies as well. As a result of this experience, we have a comprehensive understanding of what providers can expect during the audit process, and we know what providers need to do in order to avoid unjustified liability.
Is Cigna auditing your healthcare practice? If so, here are 10 important facts you need to know:
1. Cigna Healthcare Audits Can Lead to Substantial Liability
If you have never been through a Cigna audit before, the first thing you need to know is that Cigna healthcare audits can lead to substantial liability. Cigna’s auditors will be looking for any evidence of potential billing violations; and, if your practice’s on-hand documentation does not clearly establish compliance, Cigna’s auditors will assume that this is indicative of fraud.
It is not unusual for providers to face tens of thousands, or even hundreds of thousands, of dollars in recoupment liability following Cigna healthcare audits. Cigna may impose prepayment review and other penalties as well. However, in many cases these penalties are unjustified, and providers will be able to fight back by executing a focused and strategic defense.
2. Cigna Healthcare Audits Can Also Lead to Civil or Criminal Healthcare Fraud Investigations
If Cigna’s healthcare auditors uncover evidence of billing fraud (or what they believe to be evidence of billing fraud), they may also refer providers to federal authorities for further inquiry. The U.S. Department of Justice (DOJ), U.S. Department of Health and Human Services Office of Inspector General (DHHS OIG), and other federal agencies conduct civil and criminal investigations into suspected healthcare billing violations. For providers accused of significant or systematic billing violations, facing a follow-on federal investigation is a very real possibility.
3. Many Providers Face Unjustified Allegations of Healthcare Billing Fraud During Cigna Audits
While some Cigna healthcare audits uncover significant billing violations, many lead to unjustified allegations. Mistakes, overstepping auditors’ bounds, flawed interpretations of governing authority, and misguided assumptions are all frequent causes of unfounded audit determinations. The risk of facing unjustified recoupment demands is a very real concern for healthcare providers targeted in Cigna audits, and it is one of several reasons why targeted providers need experienced defense counsel.
4. Providers Must Be Prepared to Affirmatively Demonstrate Compliance with On-Hand Documentation
Given that Cigna’s auditors will err on the side of fraud, healthcare providers must be prepared to affirmatively demonstrate compliance with on-hand documentation. Minimally, targeted providers will want to have the following documentation available to discuss with Cigna’s auditors as necessary:
- Healthcare billing compliance policies and procedures
- Employee training materials and billing manuals
- Documentation of medical necessity for all billed services, supplies, and equipment
- Documentation of compliance for all billed costs (i.e., substantiation of the submitted billing code and proof that services were provided by the identified licensed provider)
- Documentation of internal billing audit and enforcement efforts
Crucially, however, providers should not simply give Cigna’s auditors open access to their books and records. This can prove to be an extremely costly mistake, as Cigna’s auditors will take advantage of the opportunity to scrutinize every possible aspect of providers’ billing, recordkeeping, and patient practices.
5. Providers That Don’t Protect Themselves Can Face Unjustified Recoupments, Prepayment Review, and Other Penalties
As noted above, Cigna healthcare audits frequently lead to unjustified demands, prepayment review, and other penalties. When facing an audit, providers cannot assume that Cigna’s auditors will reach the correct conclusions.
6. Avoiding Unjustified Penalties Requires a Strategic and Proactive Approach
Given the risk that Cigna’s auditors will make mistakes, targeted providers must take a strategic and proactive approach to defending themselves during the audit process. Providers should not simply let the audit run its course and then deal with the consequences after the fact. Instead, providers should engage defense counsel to intervene in the audit promptly, and they should work closely with their counsel to steer the audit toward a favorable outcome that avoids the need for an appeal.
7. Healthcare Providers Can (and Should) Expose Flaws During Cigna Audits
Many healthcare providers feel helpless during their Cigna audits. They see auditors making mistakes, and they feel as though their financial stability rests on the auditors’ whim. However, healthcare providers do not have to give in to the audit process. To the contrary, providers can (and should) expose flaws during Cigna audits; and, with the right approach, they can prevent these flaws from leading to unwarranted recoupment demands and other penalties.
8. Inadvertent Compliance Failures and Employee Negligence Can Lead to Unfavorable Outcomes
While auditor mistakes are common, healthcare providers need to be cognizant of the fact that their employees may make mistakes as well. In many cases, inadvertent compliance failures and employee negligence will leave providers facing unexpected liability for submitting “false and fraudulent” claims. To make informed decisions during their Cigna healthcare audits, providers need to have a clear understanding of their billing records, and this involves working with outside counsel to conduct an attorney-client privileged billing compliance assessment at the outset of the audit process.
9. Facing a Cigna Healthcare Audit is Not a One-Time Event
When facing Cigna healthcare audits, it is important for providers to keep in mind that this is not a one-time event. Cigna routinely conducts multiple audits of the same providers, and those that receive unfavorable audit determinations are likely to face additional scrutiny in the not-too-distant future.
10. Providers Need to Prioritize Compliance Before, During, and After Cigna Healthcare Audits
In light of the risks Cigna healthcare audits pose, providers need to prioritize compliance, before, during, and after their audits. Providers need to have robust billing compliance programs, and they must be prepared to demonstrate compliance as necessary. If a Cigna audit uncovers compliance deficiencies, providers must promptly address these deficiencies as well so that they do not lead to additional penalties down the line.
FAQs: Defending Against a Cigna Healthcare Audit
Why is Cigna Auditing My Healthcare Practice?
Cigna audits healthcare providers for several reasons. In many cases, providers face audits as a matter of course. However, Cigna’s SI team also initiates audits based on complaints from patients, family members, government authorities, and other providers.
What are the Risks of Facing a Cigna Healthcare Audit?
Cigna healthcare audits present several risks. Most immediately, if Cigna auditors determine that your practice has improperly billed Medicare or any other payor, they can impose recoupments, deny pending claims, and subject all future claims to prepayment review. If Cigna’s auditors believe that further inquiry is warranted, they can also refer providers to federal authorities (i.e., the DOJ or DHHS OIG) for a civil or criminal healthcare fraud investigation.
How Can Providers Successfully Defend Against Recoupments and Other Penalties During Cigna Audits?
Successfully defending against a Cigna healthcare audit requires proactive efforts to prevent flawed determinations of overpayment. Providers must work with their counsel to take control of the audit process, prevent auditors from overreaching or relying on flawed interpretations of the applicable billing rules, and use their compliance documentation to steer the audit toward a favorable outcome.
Should I Engage Outside Defense Counsel for a Cigna Healthcare Audit?
Due to the risks involved with facing a Cigna healthcare audit (including the risk of facing both justified and unjustified allegations of billing fraud), we advise that all healthcare providers engage outside defense counsel. At Oberheiden P.C., our lawyers rely on notable experience to protect providers during all stages of the audit process.
Discuss Your Cigna Healthcare Audit with a Senior Healthcare Defense Attorney at Oberheiden P.C.
Do you need outside counsel for a Cigna healthcare audit? If so, we encourage you to contact us promptly for a complimentary initial consultation. To speak with a senior healthcare defense attorney at Oberheiden P.C. in confidence, call 888-680-1745 or tell us how we can help online today.
Cigna Audit Defense Attorneys