Anthem Healthcare Audit Defense Lawyers

We Help Providers Nationwide Avoid Unjust Recoupments and Other Penalties During Anthem Healthcare Audits

Lynette Byrd
Attorney Lynette Byrd
Healthcare Fraud Team Lead
Former Federal Prosecutor
Nick Oberheiden
Attorney Nick Oberheiden
Healthcare Fraud Team
Kevin M. Sheridan
Kevin M. Sheridan
Healthcare Fraud Team
Former FBI Special Agent
Wade McFaul
Wade McFaul
Healthcare Fraud Team
Former HHS-OIG Assistant Special Agent-in-Charge

Working with Anthem is a necessity for all types of healthcare providers. But, while providers may need to rely on Anthem to keep their lights on, they also need to be very careful to maintain compliance. Anthem regularly audits providers for compliance, and Anthem healthcare audits can lead to substantial liability for those who are not adequately prepared.

If your practice is facing an Anthem healthcare audit, we can help. Oberheiden P.C. is a team of highly experienced healthcare compliance and defense lawyers who work with providers nationwide. We work with all types of providers not only to help them avoid unjust recoupment demands and other penalties, but also to help them minimize their risk of facing additional scrutiny from Anthem in the future.

Did You Receive an Anthem Healthcare Audit Letter?

Providers typically learn that they are facing an Anthem healthcare audit when they receive a letter in the mail. Once you receive this letter, the clock starts ticking. You have a limited amount of time to respond; and, if you don’t respond, Anthem can treat this as grounds to deny any claims identified for post-payment audit or pre-payment review.

But, while providers must submit timely responses when facing Anthem healthcare audits, they must also respond carefully. Submitting too much documentation, too little documentation, or the wrong documentation to Anthem can have adverse effects. Submitting too much documentation or the wrong documentation can lead to Anthem reviewing payments that fell outside of the scope of the audit initially, and submitting too little documentation can lead to a presumption of billing fraud.

Put our highly experienced team on your side

Dr. Nick Oberheiden
Dr. Nick Oberheiden



Lynette S. Byrd
Lynette S. Byrd

Former Assistant U.S. Attorney


Ellen Comley
Ellen Comley

Senior Counsel


Roger Bach
Roger Bach

Former Special Agent (OIG)

Steven Taylor
Steven Taylor

Healthcare Compliance Consultant

Susan Sage
Susan Sage

Healthcare Auditor

How We Help Providers During Anthem Healthcare Audits

With this in mind, upon receiving an audit letter it is important to engage legal counsel promptly. When you choose Oberheiden P.C., our lawyers will rely on their extensive experience representing providers in Anthem, Aetna, United Healthcare, and other healthcare audits to:

  • Determine What You Need to Do – When you engage our firm to represent you, we will review your Anthem audit letter to determine what you need to do. While these letters are usually standardized, you must still ensure that you have a clear and comprehensive understanding of what is required (and what isn’t required) of your practice during the audit process.
  • Identify, Preserve, and Collect All Relevant Documentation – It will be important for your practice to identify and preserve all relevant documentation as soon as possible. Deleting or destroying relevant records—even inadvertently or as a matter of course—can lead to problems during an Anthem healthcare audit. Our lawyers can assist you with document identification and preservation, and we can guide you through the process of collecting the documents you need to provide to Anthem.
  • Assess Your Practice’s Risk Exposure in the Audit – When facing an Anthem healthcare audit, it is important to know what (if anything) Anthem’s auditors are going to find. If your practice has submitted inaccurate (or “false or fraudulent”) billings, this is most likely a matter you will want to address proactively rather than allowing Anthem’s auditors to uncover it on their own.
  • Deal with Anthem’s Auditors on Your Behalf – To protect themselves, healthcare providers need to play an active role in the audit process. When you choose Oberheiden P.C., our lawyers will deal with Anthem’s auditors on your behalf. We will serve as a conduit between your practice and Anthem, and we will ensure that Anthem’s auditors do not overreach.
  • Challenge Flawed Assumptions, Methodologies, and Calculations – In addition to preventing Anthem’s auditors from overreaching, we will also help ensure that they do not reach faulty conclusions based on flawed assumptions, methodologies, or calculations. With in-depth knowledge of the relevant billing rules and regulations, our lawyers can quickly identify when Anthem’s auditors make mistakes.
  • Steer the Audit Toward a Favorable Outcome – All of our efforts will be focused on steering your practice’s audit toward a favorable outcome. Ideally, this will involve avoiding recoupments, prepayment review, and other penalties entirely. We have had significant success representing providers in healthcare audits, and we can use our experience to your advantage.
  • File an Appeal if Necessary – Sometimes, there is simply nothing providers (or their counsel) can do to prevent Anthem’s auditors from reaching the wrong conclusions. If your practice is facing unjustified penalties, we can handle the appeal process on your practice’s behalf. Depending on the circumstances involved, this may mean dealing with other departments within Anthem to reach a fair resolution, or it may mean challenging your practice’s unfavorable audit determination in court.

While filing an appeal will be necessary in some cases, in our experience providers can generally avoid the need to file an appeal by taking a proactive and strategic approach to the Anthem healthcare audit process. Engaging defense counsel early can significantly improve the odds of a favorable outcome; and, if Anthem is auditing your practice, we encourage you to contact us promptly for a complimentary initial consultation.

7 Common Issues During Anthem Healthcare Audits

When auditing healthcare providers, Anthem examines a wide range of issues. During healthcare audits, Anthem’s goal is to identify any and all possible grounds for imposing recoupments, prepayment review, and other penalties. Some of the most common issues we see include:

1. Inadequate Patient Documentation

When reviewing providers’ clinical medical records, Anthem’s auditors scrutinize every last detail. They assign “points” to individual pieces of information, and providers must tally enough points to earn a passing score. Oftentimes, systemic failures will lead to Anthem rejecting large swaths of providers’ patient records, and this can have significant negative consequences.

2. Failure to Document Medical Necessity

A key issue in any healthcare audit is whether the provider can provide adequate substantiation of medical necessity. Medicare, Medicaid, and private health insurers only provide coverage for items and services that qualify as “medically necessary” under their billing guidelines. If a provider does not have adequate documentation of medical necessity, this will lead to a presumption that the associated billing is fraudulent.

3. Technical Billing Violations

From missing dates to missing signatures, Anthem’s auditors are also tasked with rejecting reimbursement requests that suffer from technical violations. Even if a billing itself is valid, technical issues can still lead to denial.

4. Inadvertent Billing and Coding Errors

Inadvertent use of improper billing codes, upcoding, unbundling, and other billing and coding errors frequently lead to recoupment demands during healthcare audits. Here, too, if providers cannot substantiate their billings with on-hand documentation, this will lead to an adverse presumption during the audit process.

5. Billing for Non-Allowable Costs and Services

Billing for non-allowable costs and services is another common issue during Anthem healthcare audits. This includes, but is not limited to, improperly billing for services provided by unlicensed providers.

6. Recordkeeping Failures

Perhaps the single biggest issue for healthcare providers is failure to maintain adequate and organized records. Even if a practice’s billings are 100% compliant, if the provider cannot prove it, the provider will face liability during an Anthem healthcare audit.

7. Inadequate Internal Compliance and Training Programs

In most cases, billing violations result from inadequate internal compliance and training programs. If providers do not have the necessary policies and procedures in place, they won’t be able to maintain a compliant billing program, and they won’t be able to withstand scrutiny during an Anthem healthcare audit.

FAQs: Surviving an Anthem Healthcare Audit

Anthem is Auditing My Healthcare Practice—What Should I Do?


If Anthem is auditing your healthcare practice, you should engage experienced healthcare fraud defense counsel promptly. Providers need to make informed decisions during the audit process, and these audits can lead to substantial penalties if providers fail to defend themselves effectively.

Do I Need to Engage Legal Counsel for an Anthem Healthcare Audit?


Given the risks involved, we strongly recommend that providers engage legal counsel for Anthem healthcare audits. By engaging counsel, providers can prevent Anthem’s auditors from overreaching, and they can prevent themselves from making mistakes that have the potential to lead to unnecessary and unwarranted liability.

How Do I Avoid Recoupments During an Anthem Healthcare Audit?


To avoid recoupments during Anthem healthcare audits, providers need to take a proactive approach to the audit process. They need to ensure that Anthem’s auditors consider the correct documentation, make appropriate assessments based on applicable rules and regulations, and stay within the scope of their authority.

How Can I Make Sure Anthem’s Auditors Don’t Improperly Claim Billing Fraud?


Unfortunately, there is no way for providers to guarantee that Anthem’s auditors will not improperly claim billing fraud. However, providers can substantially mitigate their risk by engaging experienced defense counsel. At Oberheiden P.C., our lawyers are highly experienced, and we have a proven record of success defending providers during Anthem healthcare audits.

Discuss Your Practice’s Anthem Healthcare Audit with a Lawyer at Oberheiden P.C.

Is Anthem auditing your healthcare practice? If so, we encourage you to contact us promptly for more information. Please call 888-680-1745 or send us your contact information online to arrange a complimentary initial consultation today.

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