Healthcare Audit – Why Me and What Should I Do?
The Experienced Healthcare Providers Audit Attorneys at Oberheiden P.C. Want to Protect Your License
The healthcare audit defense lawyers of Oberheiden P.C. have avoided license issues and criminal referrals in some of the most challenging healthcare industry audits including errors rates exceeding 80%, missing notes, missing patient care charts, medically unnecessary services or procedures, upcoding occurrences in a healthcare practice, and situations of billing for healthcare costs and services not provided. As former DOJ healthcare fraud prosecutors and defense attorneys, Oberheiden P.C. has substantial experience with the quality improvement audits and internal audit function of dental and medical health records such as:
- Audits from CMS & Intermediaries
- ZPIC Audits
- Medicare Audits
- Medicaid Audits
- Department of Labor Audits
- Tricare Audits
- Audits from Private Insurers, such as Blue Cross, Aetna, United Healthcare etc.
This Is Why the Insurance Company Will Audit You
About 50% of federal healthcare fraud indictments are the result of an underestimated healthcare internal audit. Physicians, dentists, psychiatrists, and other medical providers must realize a paradigm shift in the audit function of a healthcare organization. Previously, an internal audit was a normal occurrence that every provider would go through at some point in their medical careers. Today, this article, co-written by former prosecutors from the U.S. Department of Justice healthcare fraud section, will show that audits are more commonly targeted and designed to address those healthcare clinics and providers that were already determined to be under healthcare fraud suspicion.
The difference is important. If you receive a request for patient files, there is a good chance that the request is the result of an internal review process, not a random selection. Nowadays, CMS, Medicaid, Medicare, and increasingly private insurance companies follow the data-analysis model. In essence, computer data calculates and analyzes what healthcare providers should be audited, rather than the more lottery-type random approach previously utilized.
What Happens in a Healthcare Audit?
Stage 1: Origin of the Audit
The vast majority of an internal audit functions in healthcare originate from one of two things: a patient complaint or a computer analysis review. Patients have enormous credibility when they report fraud, waste, or abuse to a federal program administrator or private insurance. In particular, when the complaint is in writing, detailed, and specific, there will be almost no payor that will not initiate a healthcare inquiry. Providers aware of a (credible) patient threat should contact an attorney for at least a brief consultation to discuss the seriousness of the threat and to contemplate early countermeasures, as recommended. More difficult to tackle, because they occur without awareness or even suspicion of the provider, are audits that are computer-generated. In essence, government or insurance computer programs will create lists of which doctor in a given geographical area prescribes the most opioids, which dentist bills the highest amounts to Medicaid, and which psychiatrist sees more patients than any of the competitors. Such “outlier” calculations are tricky because once experienced lawyers get involved, they often notice that the data used by the government is like comparing apples and oranges in different areas by comparing top-specialists in a certain field (e.g. vein surgeons) with regular orthopedic surgeons to (surprisingly) conclude that the vein surgeon bills more vein procedures than a regular surgeon.
Stage 2: Internal Fraud Suspicion Determination (Fraud Investigator Unit)
Depending on the validity of the findings within the initial stage, the case is then assigned to an auditor or fraud investigator. The difference is critical. In the first case, the internal audit is likely computer generated and not signed by an identifiable individual. In the case of an assignment to a fraud investigator, the internal review resulted in a fraud suspicion and the internal audit is now prepared and handled by a fraud investigator. As the name connotes, the fraud investigator is tasked to unmask healthcare fraud and to possibly make consequential recommendations such as a referral to DOJ or an exclusion or payment suspension. It would be a fatal mistake to treat an audit signed by a fraud investigator as a routine inquiry. Similarly, if the internal audit request is computer produced, it is likely that the computer analysis suggested that you are a billing outlier or display some other billing irregularity (frequency of a certain code, use of a certain code versus a lower code etc.).
Stage 3: Request for Certain Medical Records
It is only now that a provider becomes aware of the pending internal audit and review process. Either by mail or through personal delivery, CMS and other payors will notify a provider of the patient chart request. The first thing now to do is to consult with experienced internal audit defense lawyers. Again, there is very likely a reason you were selected. It may be because you are declared an “outlier” or because of a patient complaint against you. Either way, you should take an internal audit function and inspection of your practice serious. Oberheiden P.C. attorneys offer instant advice, including on weekends, in free and confidential consultations. There truly is no good reason not to make use of such a free consultation.
Stage 4: Review of Audited Charts
After the provider has complied by responding to the internal audit with the requested documents and information, the auditor or investigator will assign the files to be reviewed internally by the applicable expert staff. This review period can last for an extensive period of time due to backlog and the voluminous, document-intensive nature of medical review. Oftentimes, however, the review is cursory and purposefully bent towards declination or downgrading of claims. More and more, we are seeing that the conclusions reached in the audits inappropriately discount certain services or underestimate medical necessity.
Stage 5: File Closure, Recoupment, or Referral to U.S. Attorney’s Office
Each internal audit function results in a decision. Should the provider be referred to law enforcement, are there grounds for recoupment, or can the provider be unflagged and continue its billing and medical practice?
No matter at what stage you contact us, be assured that the Oberheiden P.C. attorneys and former prosecutors will do everything in their power to accomplish your goal: to keep your license, to not be charged, to not be excluded from CMS or expelled from the insurance network. The earlier you call us, the more we can impact the outcome.
What Should I Do When I Get Audited?
The earlier an experienced attorney is involved in the process, the higher the chances that your internal audit can be concluded quickly and without any escalation. Don’t make the mistake and let the audit run its course and then wonder, often many months later, why you are asked for more patient charts or why suddenly you are under payment suspension or visited by investigators.
Put simply, you can save a lot of time, resources, and money when you engage experienced counsel from the moment you receive an internal audit. The experienced attorneys at Oberheiden P.C. will enter into a dialogue with the auditors or investigators to find out first and foremost why you are being audited, in what stage the internal audit function is, and what avenues exist to resolve the audit in an expedited manner.
Here Are a Few Examples of How We Resolved a Tough Internal Audit
Many dentists call Oberheiden P.C. because they feel bullied by DentaQuest and other intermediaries, insurance companies, and Medicaid. We successfully represented dentists, pediatric dentists, dental groups, and oral surgeons in a variety of audits, almost all sharing some form of concerns, deficiencies, lacking x-rays, or poor documentation. Our team quickly coordinates with the auditors and, parallel to responding to the actual audit, conducts an internal audit to understand the reason for the audit function and to assess the potential exposure first. Our compliance program protocols have proven to be very helpful and a strong consideration for concluding even audits alleging lack of medical necessity (and non-provided but billed for services) discreetly.
Cardiologists are classic targets of rigid healthcare audits. With high volume of Medicare patients, CMS and Medicare intermediaries frequently select cardiologists for allegedly excessive testing and medically unnecessary therapy and services. In one recent internal audit, Oberheiden P.C. attorneys were confronted with an audit already referred to the U.S. Attorney’s Office for conducting and billing for medically not indicated tests. Even though late in the process, our attorneys undid the mistakes made by the provider (who did not use any attorney for the original internal audit) and convinced the Justice Department in a number of presentations to not bring charges against the cardiologist.
Mental healthcare professionals are often surprised to realize that they, too, are subject to audits and investigations. Even though they are less frequent and less prominent targets of billing audits, Oberheiden P.C. routinely intervenes to assist psychologists, LPCs, social workers, and psychiatrists to defend missing or incomplete notes, missing charts, or poor billing decisions. In a recent representation of a psychologist, Dr. Nick Oberheiden made sure his client passed the internal audit without a recoupment request and without a referral to law enforcement even though, as a starting point, the majority of patient files were either missing or incomplete.
Call the Trusted Federal Healthcare Providers Audit Defense Attorneys of Oberheiden P.C. Today
The healthcare internal audit defense attorneys of Oberheiden P.C. offers decades of experience as former Department of Justice officials, former federal prosecutors in charge of escalated healthcare audits and fraud investigations, and as trusted advisors to hundreds of dentists, physicians, and mental health providers across the United States. Together with a team of billing and coding experts, Oberheiden P.C. should be your first choice to process and accomplish your internal audit and quality improvement audits healthcare goals: expedited resolution without any exposure to the licensing board or law enforcement! To speak with a member of the audit team of federal healthcare fraud defense attorneys as soon as possible, call 888-680-1745 or tell us how to reach you online now.