If you are a provider with an HMO or Medicare/Medicaid and they investigate you for improper billing, you can end up with a very large financial problem. What happens is they will come in and take a sample of your billing records, maybe look at 20 different files. Let’s assume they find out that you have improperly billed on a rate of, say, ten percent. They will then — and I know this doesn’t sound right, but it’s just what they do, they will assume that you have a ten percent invalid billing rate on all of your billing, going back six years, and they will demand the money back. I’ve seen occasions where they’ve said, “We’ve done the investigation, we’ve done the audit, and we would like a check for $175,000.” This is really not a good thing. Sometimes it’s $40,000 they want, sometimes it’s $100,000, but it’s a lot of money.
There are ways to deal with this and argue with them and take another point of view, but it’s a problem. It’s one you actually need an attorney to deal with, and/or an accountant, because you’ll want to show that your billing was actually accurate or that their audit was inaccurate. In any event, these issues can be serious and can have a long-term financial downside for you. The really worse possible outcome is that the HMO or Medicare says, “We dislike what you’ve been doing so much we’re going to remove you from our list of providers.” Then that gets reported to the Department of Health or the Department of Education, and that starts another investigation process, which we really don’t want to see.