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
United HealthCare Audits
We represent healthcare providers nationwide in United HealthCare audits. Our senior healthcare defense lawyers and billing compliance consultants can help you avoid reversals and other negative repercussions.
United Healthcare is the nation’s largest healthcare payor. In addition to providing private insurance coverage, United HealthCare also administers various types of Medicare plans, and it is responsible for hundreds of billions of dollars in healthcare billings annually.
Despite its enormous revenue, United HealthCare continues to focus a significant amount of time and resources on auditing healthcare providers. United HealthCare audits are meticulous and extremely detailed, and they target individual providers’ billings on a claim-by-claim basis. While this might seem incongruous for a company that is the largest healthcare company in the world by revenue, United HealthCare’s audit program is a revenue center of its own, as audits often result in substantial “reversals” of claims previously paid.
Experienced Defense Counsel and Billing Compliance Consultants for United HealthCare Audits
Our firm represents healthcare providers throughout the United States in United HealthCare audits. This includes audits targeting providers’ direct billings to United HealthCare as well as audits targeting Medicare compliance. Our nationwide network of healthcare defense lawyers and billing compliance consultants offers remarkable experience, and we have a proven track record of helping providers avoid liability for reversals and other penalties.
Due to the complexity and risks of United HealthCare audits, when facing an audit, it is extremely important to be able to rely on experience-based advice. At Oberheiden P.C., we have represented healthcare providers across the country in thousands of audits and investigations. This includes audits conducted by United HealthCare and other private insurers as well as audits and investigations conducted by state and federal authorities. This comprehensive experience – which includes prior experience as healthcare fraud prosecutors and law enforcement agents – allows us to take an all-encompassing approach to defending our clients during United HealthCare audits. We are able to assess our clients’ risks from all angles, and we are able to execute targeted defense strategies that take all pertinent considerations into account.
Understanding the Complexities and Risks of United HealthCare Audits
While United HealthCare regularly audits participating healthcare providers for compliance, a United HealthCare audit is not something to be dismissed as a routine or inconsequential event that takes place as a matter of course. In order to avoid liability for reversals and other negative repercussions, providers must take a proactive approach to protecting themselves during the audit process.
During a United HealthCare audit, auditors will request access to the practice’s billing and patient records, and they will meticulously scrutinize these records for any evidence of compliance deficiencies. Even minor technical deficiencies such as missing dates and signatures will be flagged as issues that represent noncompliance, while larger issues (or perceived issues) can trigger even more in-depth scrutiny. Once the audit is complete, United HealthCare will disclose its findings to the provider, and the provider will be left to either accept the findings or request an appeal.
While reversals (or recoupments) are the most-common penalties imposed as the result of United HealthCare audits, the company’s provider contracts allow for the imposition of additional penalties as well. Denial of pending claims and pre-payment review of future claims are both possibilities, as is termination of the provider’s payment eligibility. If an audit reveals evidence of healthcare fraud, United HealthCare may also refer the provider to the Centers for Medicare and Medicaid Services (CMS), the U.S. Department of Health and Human Services Office of Inspector General (DHHS OIG), or the U.S. Department of Justice (DOJ).
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)
15 Potential Issues During United HealthCare Audits
While the list of issues that can lead to reversals and other penalties during a United HealthCare audit is virtually endless, there are certain issues that tend to come up more often than others. For example, the following are 15 relatively common issues that can lead to unfavorable outcomes for providers during United HealthCare audits:
Billing for services, tests, medications, or supplies not provided (referred to as “phantom billing”)
Billing for services, tests, medications, or supplies that do not qualify as medically necessary
Double-billing United HealthCare and patients, Medicare, or other insurers
Failing to maintain adequate patient records
Failing to maintain legible patient records
Improperly billing for telemedicine or telehealth services
Improperly billing for home health care or hospice services
Improperly billing for consultations, referrals, and discharges
Inadequate recordkeeping procedures
Inadequate staff training procedures
Preparing fraudulent certifications or other fraudulent patient or billing records
Upcoding (i.e. billing for a service at a higher rate than the one prescribed)
Unbundling (i.e. billing for related services at their individual rates rather than their reduced bundled rate)
Violating the Medicare billing guidelines
Withholding or being unable to provide patient or billing records during an audit
While intentional non-compliance and overbilling can lead to negative repercussions during a United HealthCare audit, inadvertent mistakes can be equally costly for providers. In fact, the vast majority of reversals triggered by United HealthCare audits are the result of unintentional errors made by medical and billing personnel. With this in mind, when defending against United HealthCare audits, providers must be extremely careful to avoid asserting “defenses” that are not only ineffective, but that might actually do more harm than good. Providers need to make informed and strategic decisions; and, in order to do so, they need to rely on the advice of experienced healthcare defense counsel.
With our attorneys’ and consultants’ depth of experience in healthcare audits and investigations, we are able to help our clients avoid costly mistakes such as attempting to assert “good faith” as a defense to liability for billing mistakes. We work with our clients to assess their risks and develop strategic and custom-tailored defenses, and we deal with United HealthCare’s auditors on our clients’ behalves. By taking a comprehensive and proactive approach to United Healthcare audit defense, we are able to protect our clients effectively—whether that means affirmatively demonstrating full compliance or executing alternate defense strategies in order to mitigate our clients’ liability exposure.
FAQs: United HealthCare is Auditing My Practice—What Do I Need to Know?
Q: What are the potential consequences of a United HealthCare audit?
A United HealthCare audit can have two main outcomes: (i) a finding of full compliance, or (ii) a finding of compliance deficiencies. If your practice is found to be fully compliant, then no additional consequences will follow. If your practice is found to be non-compliant in any regard, it can face reversals (repayment of previously-paid claims), denial of pending claims, pre-payment review, and possibly even contract termination.
Q: Is it possible to avoid reversals and other penalties during a United HealthCare audit?
Yes, in many cases it is possible to entirely avoid penalties as the result of a United HealthCare audit. However, in order to achieve this outcome, it will be necessary to execute a proactive defense strategy during the audit process. By engaging with United HealthCare’s auditors and taking the necessary steps to steer the audit toward a favorable result, you can avoid penalties that might have otherwise been imposed.
Q: What should I do if my practice’s billings or recordkeeping practices are not fully compliant?
If your practice’s billings or recordkeeping practices are not fully compliant, you should engage experienced healthcare fraud defense counsel promptly. While your practice may have an obligation to affirmatively address any compliance deficiencies that have been uncovered, any steps you take in order to rectify past mistakes should be guided by the advice of your practice’s defense attorneys.
Q: What factors should I consider when choosing defense counsel for a United Healthcare audit?
When choosing defense counsel for a United HealthCare audit, the most important factor to consider is the firm’s experience in healthcare fraud matters. Healthcare billing compliance is an extraordinarily complex area of the law; and, during a United HealthCare audit, numerous statutes, regulations, rules, and contractual provisions can apply. In order to maximize your practice’s chances of avoiding unnecessary liability, you need to rely on the advice of senior attorneys and billing compliance consultants who can offer insights based extensive experience in prior audits and investigations.
Q: What are my options if I disagree with the outcome of my practice’s United HealthCare audit?
If you disagree with the outcome of your practice’s United HealthCare audit, you can request an appeal. In order for your appeal to be successful, you must be able to demonstrate – with preexisting documentation – that the auditors’ findings are misguided. Due to the challenges and inherent uncertainty of the audit process, it is important to take a proactive approach to your practice’s United HealthCare audit and seek to avoid unfavorable findings if at all possible.
Speak with a Senior Healthcare Defense Lawyer or Billing Compliance Consultant at Oberheiden P.C.
Is United HealthCare auditing your healthcare practice? To speak with one of our senior healthcare defense lawyers or billing compliance consultants in confidence, call 888-680-1745 or request a complimentary consultation online now. We represent healthcare providers nationwide, and our attorneys and consultants are available to speak with prospective clients 24/7.
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