Our Former OIG Healthcare Fraud Investigators Protect Healthcare Providers During Medicare Audits
Medicare audits present substantial risks for participating healthcare providers. Not only can these audits lead to recoupment demands, prepayment review, and other administrative penalties, but they can also trigger civil or criminal healthcare fraud investigations. Providers that are facing scrutiny need to prioritize their defense, and they need to ensure that they have a clear understanding of the risks and challenges involved.
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.)
Former OIG Healthcare Fraud Investigators with Proven Results in Medicare Audit Defense
Our former OIG healthcare fraud investigators provide Medicare audit defense services for physician practices, pharmacies, hospitals, clinics, laboratories, and other healthcare entities nationwide. As a result of our consultants’ vast government experience, we are extremely well-versed in the rules, process, and procedures that govern Medicare audits. We use our government experience to our clients’ advantage, and we have a proven track record of helping providers and other businesses avoid unnecessary liability and other consequences during (and after) the audit process.
Medicare Audit Defense: What Healthcare Providers and Business Owners Need to Know
Successfully defending against a Medicare audit requires an informed approach. Healthcare providers and business owners need to have a clear understanding of the audit process, the potential outcomes, and their legal rights. When engaged for Medicare audit defense, we walk physicians, pharmacists, executives, and business owners through everything they need to know, and then we get to work quickly putting the framework in place so we can execute an efficient and strategic defense.
Here are some important facts to know if your healthcare practice or business is facing a Medicare audit:
1. You Need to Know What Entity is Conducting the Audit
While federal agencies like the U.S. Department of Health and Human Services’ Office of Inspector General (OIG) conduct Medicare audits, so do private contractors. The Centers for Medicare and Medicaid Services (CMS) engage private companies to conduct Medicare audits on a “fee-for-service” basis. This means that these companies have a financial incentive to uncover overpayments only—and this significantly influences the audit process.
But, while dealing with a MAC, RAC, or UPIC presents some unique challenges, so does dealing with the federal government. If the OIG (or another federal agency) is conducting the audit, this requires a particular approach as well. So, identifying the entity that is auditing your practice or business is the first step toward an effective defense.
2. A Medicare Audit Should Not Be a Unilateral Process
Too often, healthcare providers and business owners make the mistake of allowing auditors to examine their billing records without oversight. This invites a host of problems, and it can lead to scrutiny of billings (and other practices) that shouldn’t be subject to review. A Medicare audit should not be a unilateral process. Instead, providers and businesses that are facing audits should take a proactive approach to their defense, and they should engage a team of expert Medicare billing and audit defense consultants to deal with the audit for them.
3. Medicare Audits Can (and Frequently Do) Lead to Unwarranted Consequences
While auditing plays an important role in preventing fraud, waste, and abuse in the Medicare system, it also frequently leads to unwarranted consequences for legitimate healthcare providers and other businesses. The unfortunate reality is that even many auditors do not have a comprehensive and accurate understanding of the extraordinarily complex Medicare billing rules and regulations. Additionally, CMS’s “fee-for-service” audit program incentivizes private contractors to pursue maximum recoupments, and this unfortunately also leads to unjustified audit results in some cases.
All of this means that healthcare providers and business owners cannot trust the audit process—and they cannot simply allow a Medicare audit to run its course. Instead, they need to scrutinize auditors’ methods and conclusions, and they need to proactively address any issues that have the potential to lead to unwarranted or unnecessary consequences.
4. The Consequences of a Medicare Audit Can Be Significant
Speaking of consequences, the consequences of a Medicare audit can be significant. Under the Medicare billing regulations and CMS’s “fee-for-service” audit rules, findings of improper billings can lead to:
- Recoupment demands
- Denial of pending claims
- Prepayment review of future Medicare billings
- Additional fines and financial penalties
- Temporary or permanent exclusion from Medicare
If auditors conclude that a provider’s billing violations (or alleged billing violations) rise to the level of healthcare fraud, they can also refer providers and businesses for investigation. Investigations conducted by the OIG, U.S. Department of Justice (DOJ), and other federal agencies can potentially lead to civil or criminal charges. Some examples of audit findings that may trigger a referral include:
- Billing for “medically-unnecessary” services (as defined by the Medicare billing regulations)
- Billing for “medically-unnecessary” equipment or supplies
- Billing for services not actually rendered (auditors refer to this as “phantom billing”)
- Double-billing Medicare and other payors (whether private or public)
- Upcoding, unbundling, and other common billing and coding errors
5. Targeted Providers and Businesses Can (and Should) Take Control of the Process
At Corporate Investigation Consulting, we take control of the Medicare audit process for our clients. We intervene in the process immediately, establish lines of communication, and make clear that we will be scrutinizing all aspects of the audit. When auditors overreach or make mistakes, we address these issues right away, and we keep the audit on a narrow track so that it gets resolved as quickly and favorably as possible.
Our Process for Medicare Audit Defense
While facing a Medicare audit can be dangerous, this doesn’t have to be the case. At Corporate Investigation Consulting, we take a systematic approach to defending healthcare providers and businesses nationwide during the audit process. In all scenarios, our process involves:
- Intervening in the Audit – We intervene in our clients’ Medicare audits immediately. We let the auditors know that all communications need to run through us, and we take the burden of dealing with the audit off of our clients’ shoulders.
- Examining the Relevant Billing Records – We promptly review our clients’ relevant billing records to assess their risk in the audit. We then build custom-tailored audit defense strategies based on the circumstances at hand.
- Controlling the Auditors’ Access to Information – Throughout the process, we strictly control the auditors’ access to information. We ensure that they do not talk to internal personnel without authorization, and we ensure that they do not obtain records that are ineligible for review.
- Scrutinizing the Auditors’ Methods, Practices, and Conclusions – We scrutinize the auditors’ methods and practices throughout the process as well. When they misapply the Medicare billing regulations or calculate Medicare’s liability incorrectly, we address this right away.
- Demonstrating Medicare Billing Compliance and Proactively Resolving Issues as Necessary – When it makes sense to do so, we take steps to affirmatively demonstrate our clients’ adherence to an effective Medicare billing compliance program. When it is necessary to do so, we work to resolve issues proactively before they lead to unnecessary outcomes.
FAQs: Avoiding Unnecessary Consequences During a Medicare Audit
How Can Healthcare Providers Avoid Recoupments (and Other Penalties) During Medicare Audits?
To avoid recoupments (and other penalties) during Medicare audits, healthcare providers need to play an active role in the process. They need to engage a team of expert consultants to intervene in the process on their behalf, and they need to work with their consultants to make sure the auditors accurately calculate Medicare’s liability.
How Often Do Medicare Audits Lead to Inaccurate Results?
Unfortunately, Medicare audits frequently lead to inaccurate results. Due to the inordinate complexity of the Medicare billing rules and regulations, misinterpretation of the rules and regulations is a common issue during these audits.
How Can Healthcare Providers Take Control of Their Medicare Audits?
Healthcare providers can take control of their Medicare audits by promptly engaging an outside consulting firm to intervene in the process. At Corporate Investigation Consulting, our team of Medicare audit defense consultants (which includes several former federal healthcare fraud investigators) works quickly to take control of the process and help protect our clients.
How Important Is It to Engage an Outside Consulting Firm for Medicare Audit Defense?
When facing a Medicare audit, it is extremely important to engage an outside consulting firm. Scrutinizing auditors’ practices and methods requires a comprehensive understanding of the relevant rules and procedures, and few—if any—healthcare providers or businesses have the requisite expertise in-house.
Why Should I Choose Corporate Investigation Consulting for Medicare Audit Defense?
Corporate Investigation Consulting is a team of former federal agents and consultants who have centuries of combined experience on both sides of high-stakes Medicare fraud cases and other federal matters. Simply put, we know what is at stake in your audit, and we know what it takes to protect you.
Contact Us for a Complimentary Initial Consultation Today
Are you facing a Medicare audit? If so, we encourage you to contact us promptly to learn more about how we can help. To arrange a complimentary initial consultation with a Medicare audit defense consultant at Corporate Investigation Consulting, please call 888-352-9324 or tell us how we can reach you online now.