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Healthcare Audits

Advice for Navigating A Healthcare Audit

Lynette Byrd
Lead attorney
Lynette Byrd

Healthcare audits are complex, time-consuming procedures that can result in various negative implications such as fines, penalties, and law enforcement responses if not handled appropriately and promptly. Do not make the mistake of assuming that the audit will have no consequences or will otherwise disappear once you send the requested documents and information.

If there is one thing that all auditors and former FBI healthcare fraud agents agree on, that is this: Never handle a healthcare billing audit without securing the advice of an attorney. It is critical to receive the legal services of an experienced professional to safeguard against second audits, prevent increased federal scrutiny, and avoid the media attention regarding you and your practice.

Safeguard your license, career, and reputation with our professional advice given below! Contact Oberheiden P.C. right away!

  1. Make sure to fully read the audit letter and understand what it is asking. Be certain to provide to the auditors all the requested documents, which often includes medical records as well as invoices and purchase orders for the medical supplies and drugs given to patients and reimbursements by third parties.
  1. Be thorough. Instead of including copies of records from the dates requested in the audit letter, provide a copy of the complete record. This includes providing information that supports the services provided such as diagnostic tests, medications, and immunizations given to patients—whether this information is in the progress notes or a separate part of the chart. Providing the complete record to the auditor is critical. The complete record also includes other physicians’ records and other hospitals’ records obtained as history; consent forms; medical history questions; physician orders; and discharge and referral orders from hospitals and nursing homes. All these documents and information are essential for the auditor and even more so for your complete record.
  1. Double-check that all medical records are legible and can be understood. If there is handwriting that cannot be understood or is otherwise illegible, have that record transcribed and provide the transcription along with the illegible record to the auditor. Any records that are transcribed should be marked as transcribed with the date of the transcription. Auditors will not take kindly to inaccuracy; ensure that all your original records and all transcriptions are labeled accurately.
  1. Carefully evaluate all third-party carrier and contractor correspondences. Do not simply dismiss the seriousness of these requests by assuming that they are just routine medical records requests. Avoid delegating the matter to your office administration.
  1. Do not forget that a complete patient’s record includes diagnostic studies as well as any x-rays taken or interpreted if these tests were performed or are a part of your practice. Digital versions can be submitted on a CD.
  1. A good practice is to make color copies of all medical records where the original record has different colors and this differential contrast is significant. Other than blue or black, colors do not copy well and may therefore be illegible on standard copiers.
  1. All telephone correspondence with the auditor should be corroborated with a confirmation letter that confirms what was discussed on the telephone.
  1. After you receive notice of an audit, do not ever alter medical records, as this is fraud and is punishable by significant criminal penalties. If there are subsequent consults, test reports, orders, or prescriptions that have not been transferred to the chart yet, go ahead and fill these results in the chart so that you have a complete record.
  1. Ensure that you include a brief summary of the services and care provided to the patient along with each record. Remember that a summary is not proper for the medical records but can be used to help an auditor who is not very experienced in a specialized medical area with reviewing your materials. When you provide these summaries, clearly mark them as summaries with the current date these summaries are provided. Accurate labeling will avoid any confusion that these summaries are a part of the original record.
  1. Make sure you include an explanatory note and any relevant supporting medical literature, local coverage determinations (“LCDs”), journals of medical and psychological articles, clinical practice guidelines, etc. to support any unusual procedures or unusual billings. This information can also help explain missing record entries.
  1. Make sure you properly label each medical record copy as well as provide the page number of every record to the auditors. This can be done by printing or by hand. Labelling and numbering the pages are important steps because medical record copies can get lost, damaged, or otherwise mixed up during the copying and storing of the information.
  1. Retain copies of all correspondences and all documents that you provide to the auditor. Make sure these copies are complete and legible. Our practice is to make a complete copy of the record for the auditor, for the client, for us as the law firm, and two for future expert witnesses when providing records to third-party carrier auditors.
  1. Understand that time is of the essence after receiving a notice of a third-party carrier audit. Mark the date on the calendar that highlights when the records need to be submitted to the auditor. Take note that the due date is not the last date that you are able to mail the records but instead is the date that the records must be received at the auditor’s office.
  1. Ensure that each page of the record is copied both completely and correctly and is not missing any important information. If the record has missing information, the original copy should be recopied to make sure that the copy now has all the information. Do not submit to the auditor copies where the edges are cut off, the margins are slightly off, the copied page is slanted, or where the reverse side is not copied at all. To make a better copied image, reduce the copied image to 96%. This will avoid issues with the margins.
  1. Submit all communications to the auditor via certified or express mail and have a return receipt requested so that you have evidence of delivery.
  1. Consult and retain an experienced health law attorney as soon as possible when you receive notice of an audit so that the attorney can assist you when preparing your response. All correspondence with the auditor should be sent through the attorney or should be sent as the attorney deems best.

The advice provided above is only representative of some guidelines to employ when preparing for, navigating, and surviving a healthcare audit. This above list does not imply that you can or should perform these steps on your own without the assistance of an attorney. Instead, it provides key examples of some actions that you can take to protect your professional interests as soon as you receive a third-party carrier audit notice.

Contact Oberheiden P.C. Today

Oberheiden P.C. is headquartered in Dallas, Texas, and it regularly provides advice to clients regarding impending audits, investigations, and trial workacross the country. Contact our team of healthcare defense attorneys today to receive high-quality services from one of our attorneys via a free and confidential consultation.

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