Healthcare Providers Facing OIG Audits Need to Avoid Mistakes that Can Lead to Unnecessary Recoupments and Penalties
Healthcare providers in the United States can face scrutiny from several sources. Along with private insurance auditors and plaintiffs’ medical malpractice lawyers, this includes the federal government. Multiple federal agencies have oversight of the healthcare sector in the U.S., including the U.S. Department of Health and Human Services’ Office of Inspector General (OIG).
When scrutinizing healthcare providers, the OIG’s main focus is billing compliance. The OIG expects all Medicare and Medicaid-participating providers to strictly comply with these programs’ billing requirements. It also expects providers to have documentation that proves their compliance. During OIG audits, this documentation is critical, and providers that can affirmatively demonstrate compliance can usually resolve their audits quickly (at least relatively speaking) and without unnecessary consequences.
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 Agents Assisting Healthcare Providers with Audit Defense
But, even when healthcare providers have the documentation they need to withstand scrutiny during an OIG audit, avoiding unnecessary consequences isn’t easy. It requires an informed approach to the audit process, and it requires an in-depth understanding of the governing rules and procedures. Far too often, healthcare providers end up repaying funds they don’t have to repay, and they end up facing other penalties that they could—and should—have avoided.
We help healthcare providers avoid these mistakes.
If you are a physician, pharmacist, or healthcare administrator or executive, it is important that you seek outside help during an OIG audit. Due to the unique procedures, considerations, and risks involved, these are not matters that most healthcare providers and facilities are prepared to handle in-house. Handling an OIG audit successfully requires special expertise, and this expertise can only be gained from years of relevant experience.
Our team of healthcare audit and compliance consultants includes former agents with the OIG and other federal healthcare agencies. Combined, our consultants have centuries of combined experience on both sides of healthcare audits, including OIG audits among others. We know what to expect at all stages of the OIG audit process, and we know how to prepare and respond to ensure that providers do not face unnecessary and unwarranted consequences.
OIG Audit Defense: What Healthcare Providers Need to Know
Is the OIG auditing your healthcare practice, facility, or business? If so, there is a lot you need to know. You need to be making informed decisions, and you need to be sure that you are not doing anything that could put your practice in jeopardy. In addition to recoupments and other administrative penalties, OIG audits can also lead to civil—or even criminal—healthcare fraud enforcement actions in some cases.
5 Important Facts About OIG Audits for Healthcare Providers
OIG audits are unique procedures that present unique challenges. Here are five important facts all healthcare providers, administrators, and executives need to know:
1. OIG Audits are Complex
OIG audits are complex. They can examine years’ worth of billing records, and they can focus on numerous types of potential Medicare and Medicaid billing violations. Ensuring that OIG auditors have access to everything they need—and nothing they don’t—is a process in itself, and providers who are being audited need to take an organized and structured approach to their defense.
2. OIG Audits are High-Risk
As we mentioned above, OIG audits present significant risks. While it is very possible to resolve an OIG audit without liability, it is equally possible for an audit to lead to civil or criminal prosecution. Under no circumstances can healthcare providers afford to take the outcome of an OIG audit for granted.
3. There Are Limits On What Auditors Can Do
While the OIG has substantial authority to investigate billing fraud and hold non-compliant healthcare providers accountable, there are limits on what the OIG’s auditors can do. When facing an audit, it is critical to hold auditors to their limitations. If auditors are allowed to examine billings that are no longer subject to review, or if they are allowed access to records or personnel that are beyond the scope of their audit, this can lead to problems that could (and should) have been avoided.
4. OIG Auditors Sometimes Make Mistakes
Just like healthcare providers, OIG auditors sometimes make mistakes. This is one of the most important reasons to engage an outside consulting firm during an audit. If auditors misapply the Medicare or Medicaid billing regulations, misinterpret a provider’s billing records, or miscalculate the reimbursements that providers are rightfully owed, these are all issues that can have unjust consequences. But, without a comprehensive understanding of the rules and regulations governing OIG audits and federal billing compliance, these issues can be difficult (if not impossible) to detect.
5. There are Methods for Avoiding Unnecessary Consequences
While OIG audits can feel overwhelming (and they can be overwhelming for providers that aren’t prepared), there are methods for avoiding unnecessary consequences. At Corporate Investigation Consulting, we take a systematic approach backed by years of relevant experience to guide our clients’ OIG audits toward positive outcomes.
5 Mistakes to Avoid During an OIG Audit
As we mentioned in the introduction, mistakes made during an OIG audit can prove to be incredibly costly. Some of the mistakes we see healthcare providers make far too frequently include:
1. Giving OIG Auditors Have Full Access to Billing Records
When facing OIG audits, healthcare providers should not give auditors full access to their billing records. Instead, providers should ensure that auditors are only reviewing the records that fall within the scope of the audit.
2. Allowing OIG Auditors to Talk to Internal Personnel
While it may be appropriate for internal personnel to speak with the OIG’s auditors in some circumstances, this should not be the default approach. To avoid issues, all communications should flow through the provider’s outside consulting firm.
3. Failing to Play an Active Role in the Audit
An OIG audit is not, or shouldn’t be, a unilateral proposition. To protect themselves, healthcare providers need to play an active role in the process.
4. Failing to Raise Concerns During the Audit Process
If you have concerns during an OIG audit, you should not take a wait-and-see approach, and you should not save your concerns for the end of the process. This approach allows issues to snowball, and it is far more difficult to challenge the outcome of an OIG audit than it is to resolve issues while the audit is still pending.
5. Assuming the Outcome of the Audit Will Be Fair
Even though an OIG audit is a federal government procedure that is simply supposed to help protect Medicare and Medicaid from fraud, waste, and abuse, you cannot assume that the outcome of your OIG audit will be fair. It might not be; and, if it isn’t, you could end up facing recoupments, fines, denial of pending claims, prepayment review, and other consequences that are unwarranted.
FAQs: Avoiding Unnecessary Recoupments and Penalties During OIG Audits
What Role Can (and Should) Healthcare Providers Play in the OIG Audit Process?
Healthcare providers that are facing OIG audits should seek to control the process as much as possible. Rather than giving auditors carte blanche (as is too often the case), healthcare providers need to engage an outside consulting firm to intervene in the process, scrutinize the auditors’ work, and make sure that the audit does not extend into areas that are beyond the scope of review.
Should I Talk to the OIG’s Auditors?
When facing an OIG audit, it is important to play an active role, but healthcare providers also need to be very careful about how they interact with the OIG’s auditors. As a result, rather than communicating with the auditors themselves, it is best if providers engage a team of expert consultants to intervene. Expert consultants, like the former OIG agents at Corporate Investigation Consulting, will know how to communicate with the OIG effectively, and they will be able to immediately begin steering the audit toward a favorable resolution.
Do I Need to Engage an Outside Consulting Firm for OIG Audit Defense?
Yes, due to the risks involved, we strongly recommend that all healthcare providers engage an outside consulting firm for OIG audit defense.
How Often Do OIG Audits Lead to Recoupments and Penalties?
It’s difficult to say how often OIG audits lead to recoupments and penalties. But, what we can say is that providers face these consequences far too often. Under no circumstances should healthcare providers allow OIG audits to proceed unchecked, nor should they assume that the OIG’s findings will be accurate.
What Should I Do if I Am Facing an OIG Audit?
If your healthcare practice, facility, or business is facing an OIG audit, you should engage an outside consulting firm promptly. Our former OIG agents and other healthcare billing experts are available to handle audits nationwide, and we can consult on an emergency basis if necessary.
Speak with an OIG Audit Defense Consultant in Confidence
For more information about how we help healthcare providers avoid unnecessary consequences during OIG audits, contact us today. Call 888-352-9324 or submit your contact information online to arrange a complimentary initial consultation.