Healthcare Audits Attorneys

Healthcare providers are subject to various federal and state regulatory measures throughout their work, and audits are one of the tools of that process. Audits can be routine or severe and involve both private and government agencies. Regardless of the cause or type, a healthcare audit must be taken seriously. 

While an attorney is not always needed when dealing with an audit, there are many aspects in which a competent healthcare lawyer can ease the burdens an audit can bring. At Norman Spencer Law Group, our team of attorneys has dealt with a wide range of healthcare-related cases. We handle everything from comprehensive help during an audit to more targeted solutions a healthcare provider may need. Call us for a Free consultation!

There are several types of audits a healthcare provider may face. The two main distinctions are between internal and external audits. Internal audits are when a healthcare provider commissions an auditor or gets employees to go over its billing practices to address potential areas of concern. External audits are when an outside party, such as the federal government, state government, or an insurance company, initiates a review of a healthcare provider’s finances.

There are many external audits that healthcare providers need to understand. They include:

• Recovery Audit Contractors (RACs): The Centers for Medicare & Medicaid Services (CMS) contract with RACs to spot Medicare, Medicaid, and prescription drug plan overpayments and underpayments. RACs also look at improper payments, and they tend to focus more on overpayments.
• Medicare Administrative Contractors (MACs): MACs are also contracted by the CMS to handle Medicare enrollment, claims processing, billing errors, and coding errors. MACs often conduct audits on certain providers that are considered outliers by looking at billing data. They review claims, calculate payment amounts, adjust or deny payments, or deem that payments do not reflect services provided.
• Unified Program Integrity Contractors (UPICs): Also known as Zone Program Integrity Contractors (ZPICs), UPICs administer the Medicare Benefit Integrity Program. The main concern of UPICs is identifying suspected fraud, which they do through prepayment reviews and additional development requests. UPIC audits can start from tips given by RACs or MACs, but they can also happen due to claims processing, reimbursements, enrollments, medical reviews, and data analysis. 
• Targeted Probe and Educate (TPE): The TPE program gives MACs the ability to audit providers and suppliers with billing practices, utilization rates, or claim error rates that differ from peer institutions. TPE audits allow MACs to review all Medicare providers for services charged to Medicare. They also look at providers and suppliers with items and services billed with high national error rates. A TPE audit requires a Medicare provider to undergo three rounds of medical reviews and overpayment determinations.
• Comprehensive Error Rate Testing Program (CERTs): CERT contractors try to find the causes of claim errors and create plans to improve compliance with payment, claims processing, and billing requirements. CERTs randomly choose a sample from a list of Medicare fee-for-service claims and ask for medical records and background information on the providers that issued the claims. CERTs are only involved in determining error rates but will send overpayment and underpayment information to a carrier or a MAC.
• Compliance Audits: Compliance audits are independent reviews into whether a healthcare provider meets federal and state laws. Either companies or regulatory agencies can perform them, and they exist to judge a healthcare provider’s level of compliance with existing regulations.
• Commercial Insurance Audits: Commercial insurance audits occur when private insurance companies review a healthcare provider’s finances. Unlike government audits, healthcare providers and insurance companies establish reimbursement rates in their contracts, which also detail what types of claims can be audited. These reimbursement contracts and the parameters around auditable claims can be renegotiated.

While most audits do not result in disciplinary action, there is a chance that agencies can levy fines. In the worst cases, practices may have to be restructured or even shut down. The chances of negative action increase if an audit is poorly handled or non-compliance.

No audit notice should be treated casually. The first step a healthcare provider needs to take is to inform all staff that an audit is incoming, especially certain staff members that are more likely to receive audits. Providers should also inform risk managers, compliance officers, or healthcare attorneys. It is important to notify staff not just of current audits but also of potential audits.

The second step is to have procedures to deal with any future audits adequately. Responses to an audit are mandatory, but the time frame depends on the type and agency performing it. It takes diligence to determine the type of audit, the timeframe for a response, and how to gather the needed items.

The third step is to gather all of the documents listed in the audit. No document should be modified if it is incorrect, and only send copies unless original documents are specifically requested. 

If possible, it helps to hire an independent auditor or conduct an internal audit to get a second opinion on what a payer is looking for in the initial audit. This may also reveal other billing problems that need to be addressed. 

No matter the reason, healthcare audits are time-consuming and can have underlying complexities that require careful attention. Before responding to an audit letter, it is crucial to have a competent healthcare law attorney go over the process. An attorney can help a provider prepare for every step.

Healthcare audit attorneys can help gather all the relevant documents needed for an audit in a way that does not reveal excess information that can damage a provider. They can also help keep internal audits within the attorney-client privilege. With the right healthcare defense attorney, additional processes such as drafting templates or even appeals for an audit determination can be streamlined.

If you are a healthcare provider that has received an audit notice or are thinking about covering your bases through an internal audit, do not hesitate to call the Norman Spencer Law Group. Our healthcare law attorneys have handled many cases in the field and can provide in-depth plans to deal with any audit situation. Contact us to set up a free consultation over the phone, through ZOOM, via email, or in person.