How To Handle A Health Care Audit Or Investigation

Government and commercial insurance audits and investigations are a serious matter that healthcare organizations must address promptly and effectively. The outcome of a government or commercial insurance audit or investigation can effect the sustainability of any healthcare organization. Healthcare audits and investigations can lead to payment denials, overpayment demands, or recoupments and offsets. Also, particularly in matters involving a state or federal government, audits and investigations can lead to civil penalties, criminal charges, or both.

For these reasons, it is critical that healthcare organizations seek skilled and experienced legal counsel as soon as they find out or suspect that the organization is under audit or investigation.

Some Key Tips:

  • Find And Address Issues Preemptively: The government or commercial insurances often initiate audits and investigations after either a complaint, a suspicion of inaccurate billing or mismatched records and claims, or a lack of medical necessity. Providers who wish to avoid such issues should seek legal counsel who can help identify and rectify such issues. Attorneys at Hashmi Law Group have a profound experience in helping providers preemptively address such matters.
  • Seek Legal Representation: When you are dealing with the government, anything you say can held against you. It is important to seek legal representation early. Your lawyer can coordinate all responses to a government or nongovernment entity's requests for records or interviews of employees. This can include requests from Zone Program Integrity Contractor (ZPIC), Recovery Audit Contractor (RAC), Medicare, Medicaid, or commercial insurances.
  • Stay Organized: Organization of documentation is perhaps the most important factor in effectively addressing an audit or investigation. Attorneys at HLG recognize the sort of organization of documents that auditors and investigators seek. Our attorneys are available to conduct a mock, confidential audit and investigation to identify the strengths and weaknesses of your healthcare organization. After identifying this information, a lawyer can then proceed with gathering information, and preparing a sustainable structure for organization of records.

Are You Under Audit Or Investigation?

Healthcare organizations often wonder how and if they will find out whether they are under an audit or investigation. There are some situations in which the provider will not know until the review is completed. However, most often, audits and investigations begin with a request for medical records.

When the government or a commercial insurance requests records they often state a reason for their review. If they do not, it is critical to retain legal counsel to find out the basis for the investigation prior to engaging in any communication with an auditor or investigator.

For physicians, hospitals, home health, hospice, pharmacy, laboratories, and other providers who believe they are being audited, the Hashmi Law Group, PLLC, offers immediate and effective representation. Our attorneys can assist in reaching a resolution efficiently and effectively, easing your concerns and protecting your organization.

Free Consultations Available 24/7

The Hashmi Law Group, PLLC, has lawyers available 24 hours a day, seven days a week to answer your questions.

Based in Dallas, we represent health care providers and corporations, as well as individuals, throughout Texas and the USA. Call 214-235-9938 for a free consultation or send the firm an email.

With a consultation, you have the opportunity to speak to an attorney by phone or in person, and listen to your legal options.