What do I Need to Know About Billing Audits?

Being audited as a medical professional can be a stressful experience. This may take place if you are being accused of overbilling your patients. When facing these situations, it is important to reach out to an experienced New York medical defense attorney who can guide you through the process and protect you from an unfair or unwarranted audit. Continue reading below to learn more.

What is the Process of an Audit?

Audits on medical professionals are usually conducted regularly by the Health Maintenance Organization (HMO) and the government. This is done in order to recover any money that has been paid. Typically, insurers hire a company to do audits for them. Auditors tend to only look at a small percentage of your billing to find areas where you may have overbilled patients. This can be unfair, as it does not provide a full picture and it can lead them to assume it applies to all of your billing. In these situations, the insurer may send a demand letter that states you owe a large sum of money. Unfair audits can call your entire practice as a medical professional into question, which is why the assistance of an attorney is needed during this time. 

Can I Settle a Claim?

The best course of action when facing an audit is to settle for the lowest number possible. Settling a claim begins by speaking with the insurer and appointing your own auditors. Your auditors will audit the insurance company’s auditors. To obtain a positive settlement, three qualifications must be met:

  • The audit was not done at random
  • The audit was unreliable
  • The allegations against you were unfounded

If it is possible, it can benefit you to be able to refer to specific times where you underbilled patients and the auditors did not take notice of it.

Can I Fight a Claim?

While medical professionals are not always able to fight a claim, this does not mean it is impossible. In order to fight a claim, you must have an attorney thoroughly examine your contract with the insurer. There are sometimes cases in which a contract contains an arbitration clause that states disputes must be determined by an arbitrator first. If this is done, the medical professional is not able to appeal the decision if it is seen as unfair. It is important to note that these situations can result in an investigation and possible hearing by the Office of Professional Medical Conduct, which can possibly jeopardize your medical license if you are found guilty of billing fraud.

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.