What if the HMO Investigates Me for Improper Billing?

As a practicing physician, you must be made aware that the Health Maintenance Organization (HMO) or Medicare/Medicaid may conduct audits of your billing practices. And if they detect any errors in your billing, you may face serious financial consequences. Read on to discover what happens when the HMO investigates you for improper billing and how one of the seasoned HMO/Medicare/Medicaid audit protection lawyers at Walker Medical Law can help you through this.

What happens when the HMO investigates me for improper billing?

Usually, a practicing physician will receive a letter from the HMO requesting that they provide complete copies of their medical billing records for approximately 25 or more patients. And if the HMO finds that, out of these 25 records, a physician improperly billed at a rate of 10 recent or more, they will assume that they have been improperly billing at this rate for six years.

Ultimately, the HMO will send the physician a demand letter, which states something along the lines of “We have audited 25 charts and have found that you over-billed us by 10 percent. That is, you billed us $5,000 when you should have only billed us $4,500. Further, over the last six years, you billed us $400,000. By applying the 10 percent figure, we hereby demand that you return to us a total of $40,000.”

This may be seen as unfair, as the HMO only looked at a very small sample of bills and is now accusing a physician of over-billing for their services for years.

How do I handle an accusation of improper billing?

If you are being accused by the HMO of improper billing, you may have to start negotiating. That is, you may have to collect pieces of evidence that point to the following arguments:

  • The audit that the HMO conducted was not random.
  • The audit that the HMO conducted was not reliable.
  • The HMO’s allegation of overpayments is unfounded.
  • The HMO conveniently forgot the instances of underpayments.

And the best piece of evidence is to compute your own calculations and compare them against the HMO’s calculations. This is best done by retaining the services of an auditor. Essentially, your auditor will be auditing the HMO’s auditors. Ultimately, the goal of this is to negotiate down to a reasonable settlement figure that is far below what the HMO’s original demand letter stated.

Though, instead of settling your claim, you may want to fight your claim. This may be a riskier route, as an adverse decision may open up an investigation and a hearing against you. All in all, this settlement or trial process may be made easier with sound legal advisement from one of the competent HMO/Medicare/Medicaid audit protection lawyers. Contact Walker Medical Law as soon as you possibly can.