Trusted Legal Guidance For Providers Facing Health Care Billing Audits Or Payment Disputes
Few words inspire more fear and trembling than that ominous five-letter term – “audit.” In the health care industry, external audits can be just as threatening – if not more so – as in the financial or tax sectors. Given the complexities of medical coding, not to mention the sheer volume of paperwork involved, the possibility of errors or improper billing is vast. In the worst cases, adverse audit findings can lead to regulatory enforcement actions, fraud investigations and even serious criminal charges.
At Roberts Law Group in North Carolina, we advise health care providers facing the critical junctures of Medicare/Medicaid and third-party payor audits as well as prepayment reviews, claims disputes, internal audits and the like. We understand it’s more than just your bottom line at stake. It’s also your reputation, resources, and, potentially, your licensure. You can count on our lawyers to develop strong strategies for protecting all of these interests.
Medicare/Medicaid Audits And Prepayment Reviews
Providers who bill Medicare or Medicaid can become targets for a wide range of audits. The Centers for Medicare and Medicaid Services (CMS) rely on multiple contractors to identify medical billing errors, recoup overpayments, detect fraud and educate providers on proper billing procedures. This “alphabet soup” of potential auditors includes:
- MAC: Medicare Administrative Contractors conduct prepayment and post-payment audits to identify improper billing and coding.
- RAC: Recovery Audit Contractors deal with fee-for-service plans. Because these contractors earn contingent fees for uncovering improper payments, they have a financial incentive to flag potential overpayments and pursue reimbursement aggressively.
- ZPIC: The most ominous of auditors, Zone Program Integrity Contractors focus on fraud and abuse. AdvanceMed is responsible for handling these audits in North Carolina. If these audits uncover evidence of fraud, the case will be referred to the FBI or HHS Office of the Inspector General for further investigation.
- CERT: Comprehensive Error Rate Testing auditors collect data for establishing industry-wide billing error rates. However, they may still refer evidence of improper billing to other contractors for review.
- MIC: Medicaid Integrity Contractors conduct pre- and post-payment audits for Medicaid claims.
- TPE: Targeted Probe and Educate auditors typically review several rounds of medical billing. The goal of these audits is to educate providers on proper billing practices rather than recuperate improper payments, but they may still result in adverse actions.
The auditing process typically begins with a notice and request for additional information. Time is of the essence, as the deadline for complying is swift. However, the need for timely action shouldn’t outweigh the benefit of a careful and thorough response. Our attorneys can help providers respond appropriately. We can assist with the evaluation and management of the audit throughout the entire process.
We also assist providers with payment disputes such as claim denials by private insurance companies, coding edits and errors. For claims disputes involving Medicare/Medicaid, we can provide strategic representation at all stages of the appeals process, including:
- Hearings before an administrative judge
- Hearings before the Medicare Appeals Council
- Judicial Review