HMO/Medicare/Medicaid Audits

HMO / Medicare / Medicaid Audit Protection Lawyers

medical-563427Representing NY Clients Faced with Billing Audits

Physicians conduct their business under the microscope of various organizations and institutions that scrutinize everything from their ability as a professional to the way they bill patients. HMO’s and the government are routinely auditing physician billing records in an attempt to recover money that has been paid. Often, the insurer will retain a company to do the auditing and pay that company a percentage of the money that is recovered. The auditing company looks at a very small sample of the physician’s billing and tries to find a place where they can say the physician over-billed for services. Then, the auditor does a mathematical calculation and comes up with a percentage that was over-billed.

The next step is to assume that percentage applies to all of the physician billing over a long period of time. In other words, the insurer assumes that the physician has routinely overbilled for services at the same percentage for all of the unaudited billing. What follows is a “demand” letter from the insurer stating, for example, “We have audited 25 charts and have found that you over-billed us by 30%. That is, you billed us $5,000.00 when you should have only billed us $3,500.00. Further, over the last six years, you billed us $400,000.00. By applying the 30% figure we hereby demand that you return to us a total of $120,000.”

Clearly, this is a very dangerous situation for the physician. Should this battle be fought? Where will the fight be held? What are the consequences of losing? It is in your best interests to try to settle this claim at the lowest possible number. To be successful, you need the help of an effective attorney that has experience with this process.

Settling a claim 

First, you need to address the issue with the insurer. You will need to retain your own auditors who, in effect, audit the insurer’s auditors. You need to demonstrate that the audit was not random, not reliable, the allegations of overpayments were unfounded and more. You should even bring to light the instances of underpayments that were conveniently forgotten. Much of this must be done to drive down the percentage of overpayments used to substantiate its demand for reimbursement. With the right legal support, a reasonable settlement can be accomplished at a figure far below the original demand.

Fighting a claim

Should you choose to fight the claim, it is important to have an attorney look at your contract with the insurer first. Many of these contracts contain an arbitration clause stating that any dispute will be determined by an arbitrator, not by a judge or a jury. One major issue with this clause is that there is almost no way to appeal whatever decision is reached. Also, an adverse decision may open up an investigation and possible hearing with the Office of Professional Medical Conduct (OPMC), jeopardizing your medical license.

Contact Walker Medical Law

Audits by insurers are to be taken very seriously because they can result in a huge monetary loss. If you are audited, you will need a team of attorneys on your side from the beginning to challenge the validity of the audit. If you need an effective legal team to represent your rights and future, contact Walker Medical Law.