Former Federal Agents Experienced in All Aspects of Healthcare Audit Defense
Healthcare Audit Team Lead – Timothy E. Allen | Former Special Agent (U.S. Secret Service & DOJ-OIG)
Healthcare audits can spell trouble for providers that are not prepared. Whether facing scrutiny from a private insurance entity, a government audit contractor, or a federal agency, healthcare providers can face substantial liability (and potentially other consequences) if they are not in a position to defend themselves effectively.
We help providers facing all types of healthcare audits throughout the United States. From consulting with physician practices facing Medicare audits to consulting with pharmacies facing scrutiny from their pharmacy benefit managers (PBMs), our experience spans all areas of healthcare audit defense. As former Special Agents with the Department of Health and Human Services (DHHS), Department of Defense (DOD), Drug Enforcement Administration (DEA), and other federal agencies, our consultants have vast experience on the other side of healthcare audits as well.
Defense Consultants for All Types of Healthcare Audits
Within our healthcare audit defense consulting practice, we work with all types of providers facing all types of audits. This includes consulting with physician practices, pharmacies, hospitals, clinics, laboratories, healthcare systems, and other clients during:
Medicare TPE Audits
Medicare Targeted Probe and Educate (TPE) audits are intended as a corrective mechanism for providers that have improperly billed for items or services. If a provider corrects the issues identified during a Medicare TPE audit within the prescribed timeline, then the provider should not face any additional liability as a result of the audit process.
However, “passing” a Medicare TPE audit can be difficult; and, while these audits are not intended as enforcement mechanisms themselves, they can lead to further enforcement action if providers are not careful. As a result, providers need to approach these audits strategically, and it is important to ensure that the scope of the audit remains appropriately limited.
Medicare Audits
The Centers for Medicare and Medicaid Services (CMS) rely on fee-for-service contractors to conduct audits and secure recoupments from providers that have submitted “false and fraudulent” billings. While Medicare TPE audits are limited in their purpose and scope, the same is not true of Medicare compliance audits. These audits can present substantial risks for providers, and defending against a Medicare compliance audit requires a comprehensive and strategic approach.
We consult with healthcare providers facing all types of Medicare compliance audits. This includes audits involving Medicare Administrative Contractors (MACs), Recovery Audit Contractors (RACs), and Unified Program Integrity Contractors (UPICs).
Medicaid Audits
Medicaid audits present similar risks for participating providers. To defend against these audits effectively, providers need to have a clear understanding of the audit process, and they need to be prepared to substantiate their Medicaid billings with supporting documentation. We consult with pharmacies and other providers facing Medicaid audits nationwide.
TRICARE and Department of Labor (DOL) Audits
We also consult with providers that are facing audits under TRICARE and the DOL’s employee healthcare programs. These programs are subject to voluminous rules and regulations, and providers that do not devote the necessary resources to compliance can find themselves at risk for significant liability. Regardless of the circumstances involved, we work with our clients to help reduce their risk to the fullest extent possible.
DHHS Office of Inspector General (DHHS OIG) Audits
The DHHS OIG audits healthcare providers for all types of billing fraud violations. DHHS OIG audits can target various other statutory and regulatory violations as well. In many cases, these audits will present risks for follow-on investigations, and these investigations can potentially lead to civil or criminal healthcare fraud charges. As a result, it is vital that providers defend themselves effectively, and this starts with engaging a team of highly experienced consultants who can examine the inquiry from the government’s point of view.
Private Health Insurance Audits
In addition to audits targeting providers’ billings under federal healthcare benefit programs, we consult with providers facing private health insurance audits as well. These audits present their own unique set of risks and challenges. Health insurance companies almost universally reserve extremely broad audit rights; and, to protect themselves, providers need to have a clear understanding of what is permitted, what isn’t, and how to stand up for themselves effectively when the insurance companies overreach.
Pharmacy Benefit Manager (PBM) Audits
PBM audits also present unique challenges for pharmacies; and, here too, the risks of going into an audit unprepared can be substantial. Not only can PBMs impose financial liability based on years’ worth of alleged billing violations, but they can also impose prepayment review and terminate pharmacies’ contracts when they determine such actions are warranted.
Drug Enforcement Agency (DEA) Audits
For pharmacies and other healthcare providers that are subject to DEA registration, DEA audits can present significant risks. If the DEA determines that a provider has not fully complied with all pertinent laws and regulations, then suspension, loss of registration, and civil and criminal enforcement can all be on the table. In addition to healthcare billing audits, we have significant experience with DEA audits as well, and our team includes multiple former DEA agents and investigators.
Put our highly experienced team on your side
Roger Bach
Former Special Agent (OIG)
Timothy E. Allen
Former Senior Special Agent U.S. Secret Service
Chris J. Quick
Former Special Agent (FBI & IRS-CI)
Maura Kelley
Former Special Agent (FBI)
Ray Yuen
Former Supervisory Special Agent (FBI)
Michael S. Koslow
Former Supervisory Special Agent (DOD-OIG)
Marquis D. Pickett
Special Agent U.S. Secret Service (ret.)
Healthcare Audits Defense: Preparation is Vital to a Successful Outcome
When facing any type of healthcare audit, thorough preparation is the key to a successful outcome. Broadly speaking, preparing for a healthcare audit involves:
- Understanding the Scope of the Audit – First, it is essential to understand the scope of the audit. The auditing entity will provide a clue as to the issues that will come under scrutiny (i.e., MAC audits and DEA audits are different matters entirely), but this alone won’t tell you everything you need to know. To build and execute a targeted defense strategy, it is imperative to do the legwork up front to gather as much information as possible.
- Conducting an Internal Compliance Assessment – Once a provider has a clear understanding of the scope of an audit, the next step is to conduct an internal compliance assessment. This involves gathering and reviewing all relevant compliance documents, patient records, billing records, and other documentation and scrutinizing it without bias to understand what (if anything) auditors are going to find.
- Identifying Any Potential Concerns – Based on the outcome of this internal compliance assessment, the provider must identify and assess any and all potential concerns. If the audit has the potential to lead to recoupment liability, denial of claims, prepayment review, or other penalties, it will be necessary to address the relevant issues head-on. What this entails will depend heavily on the particular circumstances involved.
- Building a Body of Evidence – With most types of healthcare audits, the auditor has a lot to gain from alleging billing (or other) violations. As a result, providers must be prepared to dispute allegations of noncompliance and affirmatively demonstrate compliance with all pertinent laws, rules, and regulations. While providers need to be very careful to avoid providing too much information to auditors, they should have relevant documentation on hand so that they can fend off unwarranted recoupment demands and other adverse outcomes as necessary.
- Anticipating Issues Likely to Arise During the Audit – From misinterpreting providers’ billing records to relying on outdated rules and regulations, several issues can arise during a healthcare audit that can lead to unwarranted adverse outcomes. By being aware of these issues (and being prepared to address them proactively), providers can mitigate the risk that they will need to fight unfavorable audit determinations on appeal.
When we consult with providers during healthcare audits, these are the first steps we take to help ensure that their audits are as non-damaging as possible. However, these are by no means the only steps involved in building and executing an effective healthcare audit defense strategy. Successfully defending against a healthcare audit requires a comprehensive and custom-tailored defense strategy, and providers must be prepared to take defensive action throughout the audit process.
FAQs: Defending Against a Healthcare Audit
Do Providers Need to Engage a Consulting Firm for Healthcare Audit Defense?
Due to the complexity of the issues involved in healthcare audits and the potential consequences of an unfavorable audit determination, it is strongly in providers’ best interests to engage a qualified consulting firm for healthcare audit defense. While it is possible to appeal an unfavorable audit determination (assuming the determination is misguided), this is a much more costly option, and a reversal is not guaranteed.
What are the Risks of Failing to Effectively Defend Against a Healthcare Audit?
Failing to effectively defend against a healthcare audit can have severe consequences. This is true regardless of the nature of the audit and the billing, prescription, or other practices that are under review. While recoupments are the most common penalty, providers can face prepayment review, fines, exclusion, and other administrative, civil, or criminal penalties as well.
How Often Can Healthcare Providers Be Audited?
Generally speaking, there is no limit on how often healthcare providers can be audited. While restrictions apply to Medicare TPE audits, this is the exception rather than the rule. The best way for providers to avoid facing repeat audits is to assert a strong defense and effectively demonstrate an ongoing commitment to compliance.
Speak with a Senior Healthcare Audit Defense Consultant in Confidence
Is your healthcare practice being audited? If so, our former federal agents can help. To speak with a senior healthcare audit defense consultant at Corporate Investigation Consulting in confidence, call 866-352-9324 or tell us how we can reach you online today.