What to do if you are Faced with Unfair Billing Audits

If you are facing an unfair HMO/Medicare/Medicaid audit, you most likely know how troublesome and unwarranted they may be. Many medical professionals who are only doing their job are suddenly accused of overbilling and may end up owing insurance companies a huge percentage of their income. If you are a physician, here are some of the questions you may have:

How does the audit process work?

Essentially, if you are a physician, HMO’s and the government are regularly auditing your billing records to recover any money that has been paid. Usually, insurers will hire a company do to the auditing, and will pay them a percentage of the money recovered. A lot of the time, physicians believe this method is extremely unfair, as the auditors only look at a very small sample of the physician’s billing, in an attempt to find one or two areas where they can say a physician overbilled for services. From here, the auditor will come up with a percentage that was overbilled in one small instance, assume the percentage applies to all of the physician’s billing over a long period of time, and then he or she will receive a demand letter from the insurer, stating he or she owes them a huge sum of money. Sound unfair? Often, it is. They will take whatever percentage they come up with, multiply that with the number you “overbilled,” and then multiply that number over the last several years. If you are a physician in this situation, you may be in huge trouble. This is why you must contact an experienced attorney who will fight for your rights.

How do I settle a claim?

The goal here is to settle your claim at the lowest number possible. You will first have to address the issue with the insurer and retain your own auditors, who will essentially audit the insurer’s auditors. If you are able to demonstrate that the audit was not done at random, was not reliable, or the allegations of overpayments were unfounded, there is a good chance you may be able to help your case. It may also help if you are able to find and point out certain occasions where you underbilled patients which the insurer’s auditors failed to bring to light. 

Are there ways to fight a claim?

Not always, but you can. You must first have your attorney examine your contract with the insurer first. These contracts will very often contain an arbitration clause, which will state that any dispute must first be determined by an arbitrator. Unfortunately, if you choose this route, you usually will not be able to appeal the decision if you believe it is unfair. Additionally, an adverse decision may open up an investigation and possible hearing with the Office of Professional Medical Conduct, jeopardizing your medical license.

Contact our New York City 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.