What to Know About Billing Audits

If you are being accused of overbilling your patients, it is important to reach out to an experienced New York medical defense attorney who will walk you through the steps ahead. Continue reading to learn what to know about billing audits.

What do I need to know about billing audits?

The Health Maintenance Organization or the HMO along with the government will typically conduct audits on medical professionals. This process is used to recover any money that has been paid. Audits are typically completed by a company that is hired by insurers. The auditors will only look at a small percentage of your billing to discover the areas where you have overbilled patients. However, some might consider this to be unfair because it does not provide a full picture. This can lead to the assumption that this small percentage applies to all of your billing. The insurer may even send a demand letter that states that you owe a large sum of money. This might result in your entire practice being called into question. If this has happened to you, it is important that you retain the services of an experienced attorney who will help you take the next steps.

Can I settle a claim?

The goal you should have in mind when facing an audit is to settle for the lowest number possible. The first step you will take is to speak with the insurer and appoint your own auditors. Your auditors will audit the insurance company’s auditors. It can benefit you to be able to refer to specific times where you underbilled patients where the auditors did not take notice of. Three qualifications must be met to obtain a positive settlement:

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

How can I fight a claim?

To fight a claim, the first step you should take is to hire an experienced attorney. Your attorney will first examine your contract with the insurer. A contract can contain an arbitration clause that states that disputes must be determined by an arbitrator first. In this case, the medical professional will not be able to appeal the decision if it is seen as unfair. These circumstances may result in an investigation and possibly a hearing by the Office of Professional Medical Conduct (the OPMC). This can jeopardize your medical license if you are found guilty of billing fraud.

Contact our experienced New York City firm

When a medical professional is accused of misconduct, they must 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.