What Should I Do if I Am Unfairly Audited?

It is almost a rite of passage for a practicing medical professional to be audited by the Health Maintenance Organization (HMO). However, it is commonly argued that these audits may be conducted unfairly. Continue reading to learn what you should do if you are unfairly audited and how one of the experienced HMO/Medicare/Medicaid audit protection lawyers at Walker Medical Law can help you fight against this.

What is considered an unfair audit?

First of all, the way this process works is that the HMO will hire auditors who will look at a handful of billing samples. From these samples, they will make the ultimate determination as to whether you overbill your patients across the board. And if this is their determination, then they may send you a demand letter that orders you to pay a large sum of money.

So, practicing medical professionals may hold that the audit process in general is unfair. They may argue that such a small percentage of bills does not provide the whole picture of their billing practices. Overall, they may argue that this small percentage should not prompt such a largely consequential ruling. This is because such a ruling can put a medical professional’s entire practice and its reputation in jeopardy.

What steps should I take if I am unfairly audited?

Essentially, there are two paths you may take after being accused of overbilling your patients: entering a settlement agreement or fighting the claim.

The safer bet of the two may be settling this claim. With this, you may want to consult with your insurer and retain the services of your own auditors. This is so your auditors can audit the insurance company’s auditors. A way in which you can make your auditors’ jobs easier is if you can collect evidence of the specific dates on which you underbilled your patients. The ultimate goal of all this is to settle for the lowest number possible.

Then, there is fighting the claim, in which you will require the services of a seasoned attorney. Only an attorney will be able to fully comprehend the contract you have with your insurer. They may be able to detect an arbitration clause in this contract, which may state that any disputes must be first determined by an arbitrator. Unfortunately, if this clause exists, then you may be unable to appeal the auditor’s determination of your billing practices, even if it is blatantly unfair. What’s worse, this may prompt an investigation and hearing by the Office of Professional Medical Conduct. And if they find you guilty of billing fraud, you may suffer the ultimate consequence of losing your medical license.

This is why you need to be as confident as possible when choosing to fight this claim. But if you are ready and willing to fight an unfair audit, then you must employ one of the skilled HMO/Medicare/Medicaid audit protection lawyers today. We look forward to working alongside you.