Health Care Audit Lawyer

Dealing with federal regulations concerning health care is a difficult, yet necessary, part of doing business in the health care industry. Especially for providers who accept patients with Medicare or Medicaid insurance coverage, it is necessary to follow all the government’s rules concerning the quality of care, documentation of care, patient privacy, proper billing, and record keeping.

A failure to do so could bring severe consequences starting with a health care audit. Such an audit could then require repayment of any overcharge. The results of these audits could also affect a provider’s ability to participate in government insurance programs including Medicare, Medicaid and also require a provider to pay fines.

Potential penalties for fraud in the practice of medicine are harsh. While some audits are merely the product of oversight by Medicare and Medicaid, others are the result of a targeted investigation after a whistleblower files a complaint.

The worse case scenarios may even create criminal liability and see a court sentence a guilty provider to prison and a licensing board terminate that provider’s license to practice medicine.

In any event, it is essential to work with an attorney who could protect your rights and who could work to ensure that any audit follows the required procedures.

An experienced health care audit lawyer can provide this essential service. An attorney can review and examine any official charging documents, investigative demands or complaint that led to the audit. The attorney can work to determine a proper strategy for preparing a defense.

Finally, a lawyer could represent your interests in both State and Federal Courts in case of a criminal or civil charges that may result from the outcome of a health care audit.

What is a Health Care Audit?

In short, a health care audit is an examination of the business practices of the health care provider. While the primary mission of a health care provider is to provide treatment to their patients, they also must be sure to do so in an ethical and legal way. While this includes following the license requirements and standards of practice in their respective states, it also means following proper billing procedures when charging services to Medicare, Medicaid, and any other government program.

Rather than waiting for bad news, many providers choose to conduct an audit pro-actively and be sure they are compliant. Voluntary self-audits of a practice conducted on a regular basis can help to ensure compliance with all billing, reporting, and privacy requirements. Such a procedure can include hiring an employee whose sole job is to ensure that the practice is in compliance with all regulations.

Larger practices may hire an outside firm to perform such an audit, especially if they are concerned about potential violations, or if the nature of their practice includes complicated billing issues. Auditing firms can provide an unbiased view of a health care provider’s practices and recommend a course of action to correct any mistakes or even to self-report any violations, and lessen potential liability.

Which Medical Providers May Face an Audit

All medical providers are required to bill their patients accurately, to submit proper reports of charges and procedures to health care providers, and to keep these reports in a secure location. In today’s world, this includes the proper storage of both paper records and especially electron

Even providers who who only accept patients with private insurance may find that those insurance companies have their own auditing processes to track and approve payments. However, the subjects of most audits are health care providers who accept patients with Medicare and Medicaid.

Whether a health care provider is in compliance with all billing and reporting requirements is, therefore, often a federal matter.

Types of Audits Performed by the Federal Government

Not all audits are alike. They vary greatly in how they begin, whether the government is directly involved, and the goals of the audit. Regardless of how the audit begins, the outcome of the audit may lead to serious legal issues.

Perhaps the least formal and simplest type of audit involves one carried out by the Recovery Audit Contractors (RACs). The Medicare Modernization Act created the RAC program in an attempt to identify Medicare discrepancies and to decrease waste. The Centers for Medicare & Medicaid Services (CMS) hires the contractors to conduct these kinds of audits. The contractors have the authority to examine a health care provider’s records going back three years. An RAC audit begins with a tip from a concerned citizen or may happen when CMS has identified a health care provider as having a high propensity for error.

The Zone Program Integrity Contractor (ZPIC) audits are more generally more intense and likely to create more liablity. This is because under a ZPIC audit the health care provider must already be the subject of a fraud investigation. In a way, a ZPIC audit functions much like a subpoena in criminal cases. The ZPIC auditor has an almost unlimited authority to request documentation and can request information spanning the entire length of the provider’s business practice.

ZPIC auditors also have the authority to suspend any pending Medicare or Medicaid payments if they believe that the provider is not cooperating with their investigation.

Other forms of audits form a sort of mediation between providers and Medicare. Medicare Administrative Contractors (MACs) for example, examine all claims for payment under Part A or B of Medicare. They work to issue payments directly to providers. However, at the same time, they examine those claims for any illegal activity.

Examples of Health Care Fraud that May be the Subject of an Audit

The process of providing medical care to patients with health insurance is a relationship built on trust. The patient trusts the provider to treat their condition. At the same time, the insurance program relies on the provider to state the services provided accurately, to bill them appropriately, and not to provide any unnecessary care.

Abuses during any portion of this system could trigger an audit. At the simplest level, a provider may state that they carried out an appointment with a patient when in fact the patient did not show up for the appointment. The provider cannot then bill Medicare for this session.

Taking one step further, the provider may bill for services not provided to the patient. For example, a patient may appear for a normal set of blood tests to check cholesterol. For some reason, the patient may not want a test for a certain type of cholesterol to be included in the ordered lab work. A doctor may recognize this fact but charge Medicare for the test anyway.

Finally, health care providers may be deficient in how they protect the privacy of their patients. Medicare and Medicaid and providers are all required under HIPAA to protect patient records. A provider who endures a security breach may find that an audit follows concerning their privacy policies and procedures.

What Steps can a Health Care Provider Take to Help with an Audit?

It is important to remember that the contractors employed by CMS have investigatory powers regardless of the type of audit that they conduct. This can include the powers to gather documentary evidence, to examine any computer systems, and to examine employees and the providers.

Responding to an auditor conducting an investigation is something to consider with counsel. Some auditors have the authority to suspend any pending payments if they believe that the provider is not being cooperative. Auditors can recommend filing criminal charges or revocation of Medicare or Medicaid certification when their audit uncovers fraud.

A health care audit lawyer can help providers to respond to auditors in a way that does not impede the investigation, but at the same time, protects the rights of the provider.

The Potential Outcomes after a Health Care Audit

Of course, the most desirable outcome after an audit is for the investigation to reveal that there were no legal violations or reporting errors. The process of the audit and the stress that accompanies it can create an ordeal. It is a serious matter, but it can also hopefully be brought to a successful conclusion, one that protects a professional’s ability to continue to practice.

On the other hand, an audit also may result in charges or a federal complaint being filed.

Perhaps the most common charge that an audit may create is a violation of the False Claims Act, 31 U.S.C. 3729. That law creates liability for any person to submit a false claim for payment to the federal government knowingly. Of course, this includes liability for filing a false claim under either the Medicare or Medicaid program. A single instance of overcharging, false billing, or misrepresentation of services provided can justify a prosecution under the statute and the law carries treble damages and civil fines..

Federal prosecutors may also pursue criminal charges under the Social Security Act. 42 U.S.C. 1320a-7b says that it is illegal for any person to knowingly make any false statement in any application for a payment under a federal benefit plan. Once again, Medicare and Medicaid certainly are prime examples of these federal benefit plans. A provider who, therefore, makes a claim under these plans using information that they know to be false can be found guilty of making a false statement to a Federal benefit program. This is a felony offense where a conviction can result in a fine of up to $25,000, a prison sentence of up to five years, or both.

Of course, prosecutors can apply many many fraud statues if the results of a health care audit warrant it. They may charge a defendant with wire fraud if their actions involved the use of a telephone or over the internet or through the use of a fax machine.

A health care audit lawyer can help defendants to understand the charges that they may face if an audit uncovers fraud and protect their rights.

A Health Care Audit Lawyer Could Help to Defend You and Your Practice

Treating patients who are covered by Medicare or Medicaid can provide great benefits to a practice. These government insurance plans can provide a steady stream of income to a health care provider. They also are consistent in listing which procedures they will cover and how much they will pay for them.

However, Medicare and Medicaid are also always on the lookout for instances of apparent fraud. Activities such as charging for services not provided, double billing, improper coding, and even lapses in patient privacy could all lead to an audit.

These audits vary in how they are initiated and what their scope may be. However, the auditors themselves have great authority to gather evidence, to compel cooperation, and even to recommend criminal charges if they believe that fraud has occurred. In fact, auditors in a ZPIC audit can freeze all pending Medicare or Medicaid payments if they believe that a provider has not been adequately cooperating with their investigation.

This can, obviously, have a crippling financial impact on your practice.

If an audit does reveal apparent fraud, federal prosecutors can file charges in Federal Court. These often allege fraud committed against the Federal Government, making a false claim for benefits, or even telephone or computer fraud.

A health care audit lawyer may be able to help you protect your practice from the day that you receive notice of a pending audit to the end of any potential criminal or civil prosecution. The lawyer can work you and help provide proper defenses to allegations of impropriety that may help to deflect an auditor’s findings.

Finally, a health care audit lawyer could help to prepare your defense in court. The stakes in these cases could not be higher. A successful prosecution could affect your finances, freedom, and your ability to continue in the practice of medicine.

Contact a health care audit lawyer immediately to let them get to work protecting your future.