Amanda S. Marshall Former U.S. Attorney (Local Counsel)
Lynette Byrd Former Assistant U.S. Attorney
Roger Bach Former Special Agent (OIG & DEA)
Joe Brown Former U.S. Attorney
Healthcare Audit Defense Attorney
The Experienced Healthcare Audit Defense Lawyers 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:
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 a healthcare audit 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 an experienced healthcare audit lawyer gets 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.
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. healthcare audit defense attorney offers 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 healthcare audit 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 healthcare audit defense lawyer 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.
Put our highly experienced team on your side
Dr. Nick Oberheiden
John W. Sellers
Former Senior Trial Attorney U.S. Department of Justice
Joanne Fine DeLena
Former Assistant U.S. Attorney
Lynette S. Byrd
Former Assistant U.S. Attorney
Former U.S. Attorney
Aaron L. Wiley
Former Federal Prosecutor
Former Special Agent (OIG)
Former Supervisory Special Agent (FBI)
Former Special Agent (FBI & IRS-CI)
Kevin M. Sheridan
Former Special Agent (FBI)
Former Supervisory Special Agent (FBI)
Dennis A. Wichern
Former Special Agent-in-Charge (DEA)
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 healthcare audit defense 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 healthcare audit defense 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, our attorney 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.
FAQs: Healthcare Audit Defense
How Do I Prepare for a Healthcare Audit?
Once you find out that your business or practice is facing a healthcare audit, there are several steps you should take to prepare. At this point, the audit could already be well underway, so you will want to act quickly to mitigate any potential risk. This begins with engaging healthcare audit defense lawyers to conduct a privileged billing compliance assessment. Based on this assessment, your lawyers will be able to identify any issues that are likely to come up during the audit, and then you can use these insights to build and execute an effective defense strategy.
What Do Healthcare Auditors Do?
Healthcare auditors scrutinize providers’ and other businesses’ billing records for compliance with the applicable billing rules and regulations. Healthcare audits typically focus on billings to a specific payor, such as Medicare, Medicaid, Tricare, the DOL, or a private insurer or management organization. In addition to reviewing billing records, healthcare auditors may review patient records and other documentation as well, and they may also request to speak with the audit target’s employees. At the end of the process, auditors make recommendations regarding any recoupments or other penalties they believe are warranted.
Is It Necessary to Engage a Law Firm for Healthcare Audit Defense?
Healthcare providers and other businesses should engage a law firm for healthcare audit defense for several reasons. Most importantly, the risks involved can far outweigh the costs of engaging legal counsel. Not only should experienced legal counsel be able to expose and address any flaws in the audit process, but an audit target’s legal counsel should be able to mitigate the consequences of any billing errors as well.
It is also important to acknowledge that mistakes made during the audit process can significantly increase the risks involved. From granting auditors access to records that are not subject to review to accepting auditors’ flawed conclusions, there are several costly mistakes that experienced healthcare audit defense lawyers can help their clients avoid.
What Are the Possible Outcomes of a Healthcare Audit?
Broadly speaking, a healthcare audit has two possible outcomes: (i) the auditor can determine that the targeted entity’s billings are compliant; or, (ii) the auditor can determine that the targeted entity has submitted “false” or “fraudulent” billings. In the latter scenario—which is by far the most common—auditors may allege repeated violations of a particular billing requirement, or they may allege a multitude of billing compliance failures.
What Penalties Can Healthcare Auditors Impose?
The penalties that healthcare auditors can impose depend on the payor and the nature of the audit. In private health insurance audits, potential penalties typically include recoupments, denial of pending claims, pre-payment review, and the possibility of termination. In most federal healthcare billing program (i.e., Medicare, Medicaid, Tricare, and DOL) audits, similar penalties apply, but targeted entities also face the risk of being referred to CMS or the DOJ for civil or criminal enforcement action. However, certain types of audits, such as Medicare Targeted Probe and Educate (TPE) audits, involve special procedures and afford additional opportunities for providers to avoid penalties.
Can I Avoid Penalties in a Healthcare Audit If My Business or Practice has a High Error Rate?
Yes, even if your business or practice has a high error rate, it may be possible to avoid penalties during a healthcare audit. At Oberheiden P.C., we have significant experience protecting healthcare providers and other entities in extremely high-risk situations. If you have concerns about the risks your business or practice is facing (and which you personally could be facing as well), we encourage you to speak with one of our former federal healthcare fraud prosecutors in confidence.
Can Healthcare Audits Lead to Professional Discipline for Licensed Providers?
In addition to monetary penalties, the possibility of termination or exclusion, and the risk of facing civil or criminal enforcement action, licensed providers can also face professional discipline as the result of a healthcare audit. Healthcare auditors or authorities may refer a provider to a professional licensing board directly, or a provider may have a professional obligation to disclose an unfavorable audit result. In either scenario, the full scope of disciplinary actions can be on the table—from informal reprimands through and including license suspension and permanent license revocation.
Call the Healthcare Audit Defense Team at Oberheiden P.C. Today
The healthcare audit defense lawyers of Oberheiden P.C. offers 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 healthcare audit defense 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.
Further Information About Our Healthcare Audit Defense Services
Necessary cookies help make a website usable by enabling basic functions like page navigation and access to secure areas of the website. The website cannot function properly without these cookies.
Preference cookies enable a website to remember information that changes the way the website behaves or looks, like your preferred language or the region that you are in.
Statistic cookies help website owners to understand how visitors interact with websites by collecting and reporting information anonymously.
Marketing cookies are used to track visitors across websites. The intention is to display ads that are relevant and engaging for the individual user and thereby more valuable for publishers and third-party advertisers.
Unclassified cookies are cookies that we are in the process of classifying, together with the providers of individual cookies.