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 their experience to protect providers during all stages of the audit process.

Humana Audit Defense Attorneys

Our Lawyers are Highly Experienced in Defending Healthcare Providers in Humana Healthcare Audits

Humana audits pharmacies and healthcare providers for compliance with Medicare, Medicaid, and private insurance billing rules and requirements. If Humana auditors uncover suspected billing violations, they can impose various penalties, including recoupments and prepayment review. Humana healthcare audits can even lead to loss of eligibility (or “exclusion”) in some cases.

If your healthcare practice or facility is facing a Humana audit, you need to make sure your business is prepared. Providers and facilities targeted in Humana audits must defend themselves effectively to avoid unwarranted business disruptions and unjustified penalties. At Oberheiden P.C., our lawyers have notable experience representing clients in healthcare audits conducted by Humana, Aetna, United Healthcare, and other entities, and we can use this experience to your practice’s or facility’s advantage.

10 Steps to Take When Facing a Humana Audit

There are several steps healthcare practices and facilities need to take when preparing for a Humana audit. Our lawyers guide our clients through these steps systematically, helping to ensure that they are fully prepared to fend off unfair audit practices and unsubstantiated claims of overpayment. Some examples of steps we help our clients take before, during, and after Humana healthcare audits include:

1. Conducting an Internal Billing Compliance Assessment

Upon learning of an impending Humana audit, healthcare providers and facilities should conduct an internal billing compliance assessment focused on uncovering any issues that may come to light during the audit process. By knowing what (if anything) Humana’s auditors will find before they find it, audit targets can put themselves in a position to proactively resolve issues without unnecessary consequences.

2. Anticipating Issues To Be Raised by Humana Auditors

Based on the outcome of a provider’s or facility’s internal billing compliance assessment, the entity’s audit defense counsel should be able to anticipate any issues that Humana’s auditors are likely to raise. In making this assessment, counsel should also consider Humana’s billing enforcement priorities. These include:

Billing for services not rendered
Billing for services rendered by another provider or facility (or billing for services rendered by an unlicensed provider under a licensed provider’s name)
Billing for services at a higher frequency than other providers or facilities
Using incorrect CPT and HCPCS codes to bill for non-covered services
Upcoding, unbundling, and misusing modifiers
Billing for covered services without adequate documentation of medical necessity
Altering, forging, or falsifying documentation to support fraudulent billings

As you can see from this list, Humana’s auditors target both intentional and unintentional billing violations. They also focus on issues (i.e., billing at a higher frequency than other providers) that are not necessarily indicative of billing fraud. With this in mind, targeted providers and facilities need to ensure that they have a comprehensive understanding of all risks presented by Humana’s audit—and that they address these risks appropriately.

3. Locating Relevant Compliance and Billing Documentation

One of the keys to surviving a Humana healthcare audit is to be prepared with all relevant compliance and billing documentation. Humana auditors consider lack of documentation to be paramount to non-compliance, meaning that providers and facilities can face recoupment demands and other penalties simply as a result of being unable to affirmatively prove compliance. With this in mind, healthcare providers and facilities that are facing Humana audits should promptly locate all relevant documentation so that they can prove compliance as necessary.

4. Establishing a Response Team and Lines of Communication

When dealing with a Humana healthcare audit, a coordinated response is critical. Targeted providers and facilities should promptly establish response teams that include appropriate internal personnel who will support and work alongside the business’s outside counsel. During the audit process, providers and facilities should follow internal and external communication protocols as well, with all communications with Humana’s auditors flowing through outside counsel unless otherwise specified.

5. Overseeing Humana Auditors’ Conduct Throughout the Audit

Too often, healthcare providers and facilities play a passive role in the audit process. They allow Humana’s auditors to examine their records unchecked, only to discover significant flaws, oversights, and miscalculations at the end of the process. Instead, targeted entities need to play an active role. Through their outside counsel, they should oversee the entire audit process, and they should rely on their counsel to intervene as necessary to prevent unjustified determinations of liability.

6. Challenging Flawed Auditing Methodologies and Assumptions

Several mistakes can lead to unjustified liability for healthcare providers and facilities during Humana audits. Flawed auditing methodologies and assumptions are common, and auditors routinely commit errors that disfavor audit subjects. This includes relying on outdated guidelines or misinterpreting sources of authority such as:

Centers for Medicare and Medicaid Services (CMS) Medicare manuals
Current Procedural Terminology (CPT) and Healthcare Common Procedure Coding System (HCPCS) guidelines
Humana coverage policies and provider manuals
ICD-10-CM Official Guidelines for Coding and Reporting
Medicare local and national coverage determinations

At Oberheiden P.C., our healthcare audit defense lawyers stay up-to-date on the latest changes in the relevant laws, rules, and regulations. This allows our lawyers to quickly identify errors during the audit process and correct miscalculations before they become final.

7. Proactively Addressing Flawed Determinations of Overpayment

Proactiveness is a key theme for providers and facilities facing Humana healthcare audits. As noted above, rather than waiting until the end of an audit to correct flawed determinations of overpayment, targeted entities are much better off addressing these issues during the audit process. Not only can this eliminate the need to file an appeal (which can itself be a time-consuming and drawn-out process), but it can also prevent auditors from making more similar errors before closing the audit.

8. Documenting Errors and Misconduct During the Audit Process

In case Humana’s auditors are not willing to correct their errors during the audit process, targeted providers and facilities should document all errors and misconduct so that they can raise these issues on appeal. This is another area where it is critical to rely on experienced audit defense counsel, as most healthcare executives and practitioners will be unfamiliar with the nuanced issues that can render auditors’ coverage determinations invalid.

9. Reviewing Humana Auditors’ Conclusions and Coverage Determinations

At the end of the audit process, healthcare providers and facilities should work with their outside counsel to carefully review all of Humana’s conclusions and coverage determinations. For providers and facilities that have followed the steps outlined above, this should be an efficient process. After examining the entire audit process from a bird’s eye view, providers and their counsel will be able to make informed decisions about matters such as filing an appeal, updating the provider’s compliance policies and procedures, or preparing for the possibility of a follow-on healthcare fraud investigation.

10. Preparing to File a Timely Challenge if Necessary

If an appeal is necessary, audited providers and facilities will need to work with their outside defense counsel to file a timely challenge. Like audits, audit appeals are subject to strict rules and procedures, and successfully challenging flawed audit determinations requires experienced legal representation.

FAQs: Defending Against a Humana Audit

What Rights Do Healthcare Providers and Facilities Have During Humana Audits?

Healthcare providers and facilities have significant rights during Humana audits. This includes the right to actively participate in the audit process, ensure that Humana’s auditors do not exceed the scope of their authority, and challenge flawed auditing processes and procedures before they lead to unjustified final determinations.

Do I Need to Engage Legal Counsel for a Humana Healthcare Audit?

Due to the risks involved in facing a Humana healthcare audit, we strongly recommend engaging legal counsel. With our firm’s experience handling Humana audits and other healthcare audits on behalf of providers and facilities nationwide, we are able to provide skilled and cost-effective representation for our clients.

What are the Possible Outcomes of a Humana Healthcare Audit?

The possible outcomes of a Humana healthcare audit range from a finding of no liability to wide-ranging allegations of intentional healthcare billing fraud. When Humana’s auditors find evidence of intentional billing fraud, they may also refer providers and facilities to CMS or the U.S. Department of Justice for criminal prosecution.

How Can I Avoid Recoupments and Prepayment Review from Humana?

Avoiding recoupments and prepayment review as the result of a Humana healthcare audit requires a proactive and strategic approach. At Oberheiden P.C., we have had significant success protecting providers and facilities against unwarranted consequences, both during the audit process and on appeal.

What Should I Do if Humana is Auditing My Healthcare Practice or Facility?

If Humana is auditing your healthcare practice or facility, you should engage defense counsel promptly. You will need your practice’s or facility’s defense counsel to intervene in the audit process as soon as possible. As the audit progresses, your counsel will continue to oversee the entire process and advise you regarding the steps you should (and shouldn’t) take to mitigate your risk of facing unnecessary liability.

Speak with a Humana Healthcare Audit Defense Lawyer at Oberheiden P.C.

Is your practice or facility facing a Humana healthcare audit? If so, we encourage you to contact us promptly. To speak with a senior Humana healthcare audit defense lawyer at Oberheiden P.C. in confidence, call 888-680-1745 or request a complimentary consultation online now.

Humana Audit Defense Attorneys