In the healthcare industry, it is not uncommon to have finances and expenses under question. As everyone in the healthcare industry is attempting to run their own businesses, they want to ensure they’re not getting ripped off or spending money they don’t need to.
But when it comes to audits and investigations in the healthcare industry, they can actually have completely different intentions. If you are a healthcare professional and you’re going through an audit or an investigation, you will need to have a full understanding of what that means.
What is a Healthcare Audit?
Audits in the healthcare industry happen all the time. In an audit, you may have a bill or price of service questioned. When under audit, you simply need to provide the individual auditing you with additional information to support your price and explain how you came up with the number that you charged.
Audits can be requested by insurance companies, patients, Medicaid and Medicare, or may happen at random. The auditing process will depend on who is auditing you and what their purpose for auditing you may be.
An audit does not necessarily mean that illegal activity or fraudulent intent was present. Instead, they may just believe there was an error in billing or they would like to understand why your prices have been raised or you charge more than other medical practices in the area. ‘
While under a healthcare audit, it is important that you fully comply with the auditors. Although many audits are simply looking for ways to save money for insurance companies, Medicare, or Medicaid, audits can also unearth potentially fraudulent behavior that can come with serious consequences.
If you are under audit, you will want to consider hiring a Los Angeles Healthcare Audits Investigations Lawyer. While you can get through the audit without the help of an attorney, having an expert by your side can ensure you come out in the right light. By helping you determine which information you need to provide and what you should do and say during the audit, you can move on with your medical business as normal.
What is a Healthcare Investigation?
A healthcare investigation is much more serious than a healthcare audit. For the most part, audits are harmless and are simply looking for ways to save some money. While an audit not working in your favor could mean you need to return some cash, you don’t really need to risk losing your medical license or your business. With an audit, those reviewing your finances aren’t necessarily looking for a illegal behaviors.
But in a healthcare investigation, reviewers are looking for potential fraud or other illegal actions. Rather than simply reviewing your books and billings, someone investigating your medical practice will be looking for evidence or signs that you have not been following the law.
Investigations can be a bit more difficult to spark, but they usually begin by a tip that your practice is committing fraudulent billing practices. This may come from an employee or may even come from an auditing service that has recently performed an audit on your business.
Depending on the findings of an investigation, you or other responsible parties could face additional trials and potentially jail time. If anything, an investigation could ruin the reputation of your practice and your doctors.
Because of the serious consequences that can come from an investigation, you won’t want to go through the process without a Healthcare Audits Investigations Lawyers. With the help of a lawyer from the very beginning, you and your legal team can develop a defense for what activities the investigators will find. Additionally, an attorney can help negotiate a settlement or reduce potential jail time and consequences if illegal activity is found.
If you are being audited or investigated, don’t hesitate in contacting a Los Angeles Healthcare Audits Investigations Lawyer to see what they can do for you. The sooner you get legal help on your side, the better chances you have at coming out on top. With expert legal attorneys to walk you through the auditing or investigation process, you can ensure you did everything you could to win your case.
Receiving a healthcare audit letter from the federal government can be a confusing and intimidating experience. Before fearing what this could mean for your practice, thoroughly read the audit letter to get a clear picture of which entity is making a request.
Several different government agencies are tasked with uncovering health care fraud to prevent further incidents. Under the direction of the Centers for Medicare and Medicaid Services (CMS), some agencies simply want further documentation or information that supports a claim.
Types of Audit Letters
There are essentially four types of audit letter that you can receive from the government:
• Medicare Administration Audit – this is a request to conduct medical reviews for fee-for-service claims. If you receive this type of letter, additional documentation is needed to justify the purchase of medical equipment or medical services for the patient.
• Recovery Audit – this is an attempt to identify and correct any overpayments or underpayments.
• Zone Program Integrity Audit – suspected cases of fraud fall under this category where the auditor reviews medical records, conduct site visits and interviews. The focus is to determine if there is a pattern of improper billing.
• Comprehensive Error Rate Testing – this is a random selection and review of statistically identified rates of improper payments.
Your Next Steps after Receiving an Audit Letter
As a healthcare provider, you should prepare to answer the audit letter. Inform your staff about the possibility of auditors visiting the facility. Develop a plan for responding to the request in a timely manner.
There are times when the audit letter is set directly to an employee who is responsible for billing Medicare for the services you provide. Make sure your staff is aware that receiving an audit letter from the government is a possibility.
Responding to the audit letter is never an option. Based on which entity sends the audit letter determines the time period to deliver a mandatory response. Although a timely response is vital, you should never rush it.
Consider the reasons why the information is being requested. You also want to be aware of the risks to your practice if incorrect or damaging information is given to a government agency. Therefore, it is in your best interest to speak with a qualified healthcare audit lawyer.
Before deciding on how you and your staff should respond to the audit request, you should hire a lawyer. He or she will confirm what is being requested and what information you should submit. Generally, the time sensitive nature of these letters require establishing a relationship with a competent healthcare audit attorney before one is received.
In this manner, you and your legal counsel can prepare a thorough response the audit request. He or she knows the law and the repercussions of missing a deadline. Your attorney can also advise on what is appropriate to send. If the audit ends with a determination of fraud, you may have several options such as rebutting and requesting a redetermination.
Legal representation can help to keep your healthcare practice providing much-needed services to patients.
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