What Happens When an Insurance Company Audits the Billing Practice of a Physician, Dentist, or Any Other Healthcare Provider?

We recently concluded a negotiation with a physician and one of the health care insurance companies with which he has done business for years. This issue began, as most do, with a letter from the insurance company stating that they were asking that the doctor provide complete copies of the medical records of more than 25 patients. The doctor did so, as the contracts with these companies require that the records be produced on demand, and then about a year
went by without any comment from the company. But the company did not go away, and finally, a letter arrived stating that the audit had uncovered improper charges going backs many years and that the doctor needed to repay a large sum of money. At that point, we were retained and we began to investigate the matter.

When this happens there are several issues to bear in mind, and some of them are as follows:

  1. It must be determined when the deadline is to appeal the company’s findings. You truly do not want to fail to file an appeal in a timely fashion.
  2. The physician and the attorney must meet to review the audit findings and to determine if some, or all, of the items, can be successfully challenged on a medical basis.
  3. An expert physician should be selected to review the records so that if you have to defend the case at a Hearing, you can have medical testimony on your side.
  4. You should retain the services of a billing expert who can review the audit itself and advise as to whether the company’s audit can be discredited.
  5. There should be a demand made for the Excel Spreadsheet that the company’s auditors put together to do the audit. This will have the details of the audit.
  6. The contract between the physician and the company has to be obtained along with the company’s handbook. These will give you the exact terms of how this audit will be addressed.

After obtaining the above items, the physician will be in a much better position to determine the extent of his/her possible financial liability from this audit. No doubt some of the claims from the company can be defended, but it has to be understood that a certain number of the claims might well be valid. There has to be a clear understanding
as to which is which so that a realistic negotiation can take place. I can say that on numerous occasions these matters end without any repayment by the health care provider, but sometimes it is prudent to negotiate a reasonable settlement amount and put the issue to rest.

It must be emphasized that these claims can become licensure issues or even criminal cases. This is because the insurance company can take the position that the billing being audited is not simply wrong, but was in fact fraudulent in nature.

Obviously, these matters have to be treated with care and with an understanding of the possible consequences. This is not the place to be unrealistic or to fail to pay attention to the issue. These matters are very serious and need careful attention and analysis.