Physician Audits in New York

Medical professionals work hard to ensure patients are treated properly. Because of this, they are compensated in return for their work. When patients are billed, it is required to be the proper amount for the care they received. However, sometimes bills are out of the ordinary. If a physician overcharges a patient, they may be held responsible for this offense. This may require an audit of a physician to be conducted to look into how they are billing their patients. If a medical professional is found to be overcharging their patients, they may be held liable for billing fraud.

There are two types of billing audits: a prospective billing audit and a retrospective audit. A prospective audit is conducted by someone in the staff who is assigned this role. This takes place before the claims are submitted by the individual paying. Alternatively, a retrospective audits occur after the claim is submitted and the physician’s errors are identified. Medical professionals who are accused of over-billing patients may wish to seek legal representation from an experienced medical defense attorney.

Reasons to be Audited

When a physician is audited, the auditing company assesses a small sample of what the physician billed to look for over-billing. Audits may be conducted for a number of reasons. This may include:

  • Improper procedural and diagnosis coding
  • Protection from fraudulent claims
  • Issues with unbundling procedures
  • Use of outdated codes for procedures
  • Determining medical necessity

After analyzing the sample, the auditing company will come up with a percentage of the billing that was too high. The company will then most likely demand the physician pay back all the money that they overbilled.

Settling a Claim

When a medical professional is accused of overcharging for their bills, they should seek an auditor on their own terms to help with their defense. This gives the physician an opportunity to prove the claim is false with their own audit. This can support their case and show that the insurance company’s claims are not backed up with the correct evidence. They will be required to show the audit was unreliable and that the allegations are untrue. It is also beneficial to enlist legal help while facing these claims. Experienced attorneys can guide doctors towards the best solution for them.

In the event that a medical professional wishes to fight a claim, it is important to have an attorney look through their contract with the insurer. Often times, a contract contains an arbitration clause stating that all disputes will be determined by an arbitrator instead of a judge or jury. This is crucial to understand because, with this clause, it is extremely difficult to appeal the decision that is reached.

Contact our Firm

When a medical professional is accused of misconduct, it is essential that they 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.