Defenses Against Unfair HMO/Medicare/Medicaid Audits

Those facing unwarranted HMO/Medicare/Medicaid audits are most likely worried about how they will affect their practice for years to come. If you are accused of overbilling patients, you may owe insurance companies a huge sum of your income, which is completely unacceptable. If you find yourself in this situation, you must read on to learn more about the process and your legal options going forward:

What happens when I am being audited?

HMO’s, as well as the government, regularly audit physician’s billing records so that they can recover money that has been paid. Unfortunately, insurers generally hire companies to do to the auditing for them, and oftentimes, they only look at an extremely small sample of the physician’s billing records. From here, they will attempt to find any potential areas where a physician may have overbilled a patient, even if it was only once in his career, and then skew the report by assuming the rest of the physician’s billing record will show the same trend.

Once this has been done, physicians will often receive a letter from the insurer, seemingly out of nowhere, stating that they owe a large sum of money. Essentially, the formula is this: whatever percentage they claim you overbilled will be multiplied by the number you “overbilled,” and then multiply that number over the last several years. If this sounds downright unfair, you’re correct. That is why if you find yourself in this situation, you must contact an experienced medical defense attorney as soon as you can.

Should I settle a claim?

Very often, it is best to settle for the lowest possible number. First, you will speak with the insurer and appoint your own auditors whose job is basically to audit the insurance company’s auditors. The three main qualifications for obtaining a positive settlement are whether you can prove that either the audit was not done at random, was unreliable, or that the allegations of overpayments were unfounded. If you can, it may help to also refer to times where you actually underbilled patients that the insurer’s auditors failed to point out.

Contact our experienced New York City firm

When a medical professional is accused of misconduct, they must retain strong legal representation. If you require a medical law attorney for your legal matters, call Paul E. Walker, an experienced New York City OPMC & OPD Lawyer. Please contact the Walker Medical Law firm to set up a free initial consultation.