Mutual Matters

Can an Audit or Regulatory Proceeding Really Happen to You?

Posted by Stephanie Dozier on Oct 12, 2018 11:55:00 AM

r_doctorconcentrating_0-2Regulation of the healthcare industry is increasing. Almost every aspect of a medical practice is now regulated, including interactions with patients, employees, vendors, and even how you bill for your services.

Though the headlines are filled with articles about million dollar settlements between the government and providers, hospitals, or pharmaceutical companies, no one thinks it will happen to him or her.

What if it does? Do you have a plan in place for when you receive a large audit demand, subpoena or civil investigative demand (CID)? What will you do if you receive a six-figure recoupment demand for billing errors from a government auditor?

Don’t wait until it happens to have a plan in place.  

You’re Being Audited…Now What?

Understanding how the audit process works and having a knowledgeable person guide you through it is essential. The government and its audit contractors do not discriminate on specialty, size or location when mining your billing data for possible errors. The auditors are looking for a wide variety of mistakes or intentional deceit. These items include things like upcoding, (using a higher paid code in place of a lower code), incorrect or inadvertent mistakes in coding, or lack of documentation.

Routine audits can quickly turn into large repayment demands from payers. These demands should not be paid automatically. You may want to consider the appeals process.

There are five steps in the appeals process:

  1. Redetermination – Typically, this can be done in-house if the organization or provider has trained personnel to prepare the appeal; however, it’s recommended that you engage counsel as soon as you get the audit.
  2. Reconsideration – This is a request by the organization or provider to have the data reviewed by a Qualified Independent Contractor who was not involved in the redetermination. It is advisable at this stage to obtain the help of an experienced healthcare attorney. The reason for the appeal and all supporting data should be presented.  
  3. Administrative Law Judge (ALJ) Hearing – At this level, the case will be heard by an administrative law judge. There are significant delays at this level due to the backlog of cases. It could take two to three years for the case to be to be heard. Only certain cases which meet the dollar amount threshold can be appealed at this level.
  4. Appeals Council Review – At this level a Medicare appeal council will review the ALJ decision and make a decision.
  5. Judicial Review in Federal Court – Only certain cases with a minimum dollar amount make it to this level, the court will review the Appeals Council’s Review and make a determination.

The appeal process can be timely and costly and there are time constraints involved in each step. These steps must be followed or you could inadvertently lose the ability to appeal to the next level. Be prepared and have a team in place that is ready to respond should you receive a demand for repayment.

To find out what to do if you receive a CID and how to stay ahead of a false claims act investigation, click below. 

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As one of the leading mutual providers of Medical Professional Liability insurance, we're here to help all healthcare professionals with the challenges they face on a daily basis. The topics we cover include: 

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