We Help Hospitals Defend Against All Types of External Audits Targeting Billing and Healthcare Law Compliance
Hospital Consulting Team Lead – Timothy E. Allen | Former Special Agent (U.S. Secret Service & DOJ-OIG)
Hospitals in the United States are subject to audits by numerous external entities. This includes governmental entities such as the U.S. Department of Health and Human Services (DHHS) and the Drug Enforcement Administration (DEA), fee-for-service audit contractors working with the Centers for Medicare and Medicaid Services (CMS), and private companies such as health insurers and pharmacy benefit managers (PBMs).
A lot is at stake during these healthcare audits. Not only can hospitals face liability for recoupments, fines, and other monetary penalties, but they can face other risks as well. Depending on the nature of the audit and the external entity involved, hospitals can face loss of registration, loss of eligibility, pre-payment review, and other costly consequences as well.
Strategic and Comprehensive Defense for External Hospital Audits
At Corporate Investigation Consulting, we help hospitals defend against external audits successfully. Our external audit defense team includes former high-ranking agents with DHHS, DEA, and other agencies. We take a strategic and comprehensive approach to helping hospitals avoid unnecessary penalties, relying on our consultants’ and specialists’ centuries of combined experience to provide custom-tailored external audit defense solutions to hospitals nationwide.
Our experience encompasses assisting with the defense of external audits involving virtually all government healthcare benefit programs and private payors. This includes (but is not limited to) external audits conducted by entities including:
- Centers for Medicare and Medicaid Services (CMS)
- Drug Enforcement Administration (DEA)
- Medicare Administrative Contractors (MACs)
- Pharmacy benefit managers (PBMs)
- Private health insurance companies
- Recovery Audit Contractors (RACs)
- U.S. Department of Health and Human Services (DHHS)
- Unified Program Integrity Contractors (UPICs)
We have experience handling Internal Revenue Service (IRS) audits as well; and, in addition to our former DHHS and DEA agents, our external audit defense team includes a former Special Agent with IRS Criminal Investigations (IRS-CI).
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.)
What To Do if Your Hospital is Facing an External Audit
As a CEO or compliance officer, if your hospital is being audited, what should you do? At this stage, it is imperative to devote the necessary time and resources to the audit. While there are some steps that you can take internally without outside guidance, you will need to engage an outside consulting firm promptly to assess your hospital’s risks and execute a sound defense strategy on your facility’s behalf.
At Corporate Investigation Consulting, when we assist hospitals with external audit defense, our approach consists of:
- Making contact with the auditing entity in order to intervene in the process and gain a clear understanding of the trigger, scope, and purpose of the audit;
- Conducting a confidential internal audit in order to assess compliance, identify any potential areas of exposure, and proactively address any compliance failures;
- Developing and executing a custom-tailored defense strategy that takes all pertinent facts, circumstances, and risks into account;
- Remaining in contact with the external auditors throughout the process, and meticulously scrutinizing their work in order to identify flawed assumptions, faulty methodologies, and other issues; and,
- Using our knowledge and experience to steer the external audit toward an outcome that avoids or minimizes any liability while also mitigating the risk of facing similar inquiries in the future.
FAQs: Defending Against External Hospital Audits
Q: Why is my hospital being audited?
Hospitals face audits for a variety of different reasons. Federal agencies, CMS audit contractors, private payors, and PBMs all conduct routine audits without specific triggers. However, all of these entities also conduct audits when they receive information that a hospital may have engaged (or may currently be engaged) in fraudulent billing practices. Additionally, if an external audit leads to substantial recoupments, this can increase the likelihood of facing another audit as well.
Q: What are the risks involved with facing an external hospital audit?
The risks involved with facing an external hospital audit can be substantial. While penalties are typically financial in nature, (i) these financial penalties can be substantial; and, (ii) in some cases, audits can lead to federal criminal prosecution for hospital CEOs and other individuals. In order to protect your hospital (and yourself), you need to defend against the audit by all means available.
Q: Does my hospital need to engage an outside consulting firm for external audit defense?
There are several important reasons to engage an outside consulting firm for external audit defense. Given the risks involved, you cannot afford to take chances. An outside consulting firm such as Corporate Investigation Consulting that has former federal agents to assist your hospital can help mitigate these risks to the fullest extent possible.
Q: Can I expect an external hospital audit to result in a fair outcome?
Unfortunately, not necessarily. The auditing process is complex, and mistakes are fairly common. Additionally, private entities such as MACs, RACs, UPICs, health insurers, and PBMs have financial incentives to maximize recoupments and other financial penalties through the audit process. In order to ensure fairness, your hospital will need advocates and advisors who can oversee the audit process with its best interests in mind.
Q: Is there anything I can do to reduce the risk of my hospital being audited in the future?
Yes, implementing and enforcing a comprehensive internal compliance program is the best way to mitigate your hospital’s risk of facing additional external audits. While government and private entities audit hospitals as a matter of course, they conduct ad hoc audits as well. By demonstrating a good-faith commitment to compliance during an external audit, you can reduce the risk that your hospital will face additional targeted scrutiny in the future. In addition to assisting with external audit defense, we also assist hospitals with establishing and maintaining compliance.
Talk to a Former DHHS, DEA, or IRS Agent about Your Hospital’s External Audit Defense Strategy
Is your hospital facing an external audit? If so, we encourage you to speak with one of our former DHHS, DEA, or IRS agents promptly. Call 866-352-9324 or contact us online to get a confidential consultation today.