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Los Angeles healthcare audits investigations lawyers

By Spodek Law Group | October 24, 2020
(Last Updated On: May 27, 2023)

In the healthcare industry, it is not uncommon to have finances and expenses under question. As everyone in the healthcare industry is attempting to run their own businesses, they want to ensure they’re not getting ripped off or spending money they don’t need to.

But when it comes to audits and investigations in the healthcare industry, they can actually have completely different intentions. If you are a healthcare professional and you’re going through an audit or an investigation, you will need to have a full understanding of what that means.

What is a Healthcare Audit?

Audits in the healthcare industry happen all the time. In an audit, you may have a bill or price of service questioned. When under audit, you simply need to provide the individual auditing you with additional information to support your price and explain how you came up with the number that you charged.

Audits can be requested by insurance companies, patients, Medicaid and Medicare, or may happen at random. The auditing process will depend on who is auditing you and what their purpose for auditing you may be.

An audit does not necessarily mean that illegal activity or fraudulent intent was present. Instead, they may just believe there was an error in billing or they would like to understand why your prices have been raised or you charge more than other medical practices in the area. ‘

While under a healthcare audit, it is important that you fully comply with the auditors. Although many audits are simply looking for ways to save money for insurance companies, Medicare, or Medicaid, audits can also unearth potentially fraudulent behavior that can come with serious consequences.

If you are under audit, you will want to consider hiring a Los Angeles Healthcare Audits Investigations Lawyer. While you can get through the audit without the help of an attorney, having an expert by your side can ensure you come out in the right light. By helping you determine which information you need to provide and what you should do and say during the audit, you can move on with your medical business as normal.

What is a Healthcare Investigation?

A healthcare investigation is much more serious than a healthcare audit. For the most part, audits are harmless and are simply looking for ways to save some money. While an audit not working in your favor could mean you need to return some cash, you don’t really need to risk losing your medical license or your business. With an audit, those reviewing your finances aren’t necessarily looking for a illegal behaviors.

But in a healthcare investigation, reviewers are looking for potential fraud or other illegal actions. Rather than simply reviewing your books and billings, someone investigating your medical practice will be looking for evidence or signs that you have not been following the law.

Investigations can be a bit more difficult to spark, but they usually begin by a tip that your practice is committing fraudulent billing practices. This may come from an employee or may even come from an auditing service that has recently performed an audit on your business.

Depending on the findings of an investigation, you or other responsible parties could face additional trials and potentially jail time. If anything, an investigation could ruin the reputation of your practice and your doctors.

Because of the serious consequences that can come from an investigation, you won’t want to go through the process without a Healthcare Audits Investigations Lawyers. With the help of a lawyer from the very beginning, you and your legal team can develop a defense for what activities the investigators will find. Additionally, an attorney can help negotiate a settlement or reduce potential jail time and consequences if illegal activity is found.

If you are being audited or investigated, don’t hesitate in contacting a Los Angeles Healthcare Audits Investigations Lawyer to see what they can do for you. The sooner you get legal help on your side, the better chances you have at coming out on top. With expert legal attorneys to walk you through the auditing or investigation process, you can ensure you did everything you could to win your case.

Receiving a healthcare audit letter from the federal government can be a confusing and intimidating experience. Before fearing what this could mean for your practice, thoroughly read the audit letter to get a clear picture of which entity is making a request.

Several different government agencies are tasked with uncovering health care fraud to prevent further incidents. Under the direction of the Centers for Medicare and Medicaid Services (CMS), some agencies simply want further documentation or information that supports a claim.

Types of Audit Letters

There are essentially four types of audit letter that you can receive from the government:

Medicare Administration Audit – this is a request to conduct medical reviews for fee-for-service claims. If you receive this type of letter, additional documentation is needed to justify the purchase of medical equipment or medical services for the patient.
• Recovery Audit – this is an attempt to identify and correct any overpayments or underpayments.
• Zone Program Integrity Audit – suspected cases of fraud fall under this category where the auditor reviews medical records, conduct site visits and interviews. The focus is to determine if there is a pattern of improper billing.
• Comprehensive Error Rate Testing – this is a random selection and review of statistically identified rates of improper payments.

Your Next Steps after Receiving an Audit Letter

As a healthcare provider, you should prepare to answer the audit letter. Inform your staff about the possibility of auditors visiting the facility. Develop a plan for responding to the request in a timely manner.

There are times when the audit letter is set directly to an employee who is responsible for billing Medicare for the services you provide. Make sure your staff is aware that receiving an audit letter from the government is a possibility.

Responding to the audit letter is never an option. Based on which entity sends the audit letter determines the time period to deliver a mandatory response. Although a timely response is vital, you should never rush it.

Consider the reasons why the information is being requested. You also want to be aware of the risks to your practice if incorrect or damaging information is given to a government agency. Therefore, it is in your best interest to speak with a qualified healthcare audit lawyer.

Hire a Healthcare Audit Investigation Lawyer

Before deciding on how you and your staff should respond to the audit request, you should hire a lawyer. He or she will confirm what is being requested and what information you should submit. Generally, the time sensitive nature of these letters require establishing a relationship with a competent healthcare audit attorney before one is received.

In this manner, you and your legal counsel can prepare a thorough response the audit request. He or she knows the law and the repercussions of missing a deadline. Your attorney can also advise on what is appropriate to send. If the audit ends with a determination of fraud, you may have several options such as rebutting and requesting a redetermination.

Legal representation can help to keep your healthcare practice providing much-needed services to patients.

The Differences Between Healthcare Audits and Investigations

In the increasingly scrutinized healthcare industry, finances and expenses are often questioned. Healthcare professionals need to have a clear understanding of the differences between audits and investigations and their varying implications.

What is a Healthcare Audit?

A healthcare audit occurs when a medical bill or service price is questioned, and it entails providing additional information explaining the pricing to the individual conducting the audit. These audits can originate from insurance companies, patients, Medicaid or Medicare providers, or random occurrences. The primary intention behind audits is typically to identify potential errors in billing or to comprehend the reasoning behind pricing differences when compared to other medical practices.

During a healthcare audit, it is essential to fully cooperate with auditors since uncovering fraudulent behaviors could lead to severe consequences. To help navigate the audit process, hiring a Los Angeles Healthcare Audits Investigations lawyer is highly recommended. Their expertise will guide you in providing essential information and can make the difference when it comes to achieving the best outcome.

What is a Healthcare Investigation?

Healthcare investigations are much more serious than audits. While the purpose of audits is mainly to identify and rectify financial discrepancies, investigations involve searching for potential fraud or illegal activities. These investigations often stem from tips regarding fraudulent billing practices – either from employees or parties that have recently audited the business.

The consequences of a healthcare investigation can be devastating, including the loss of one’s medical license, business, or even imprisonment. To minimize these risks, engaging the services of a healthcare audits investigations lawyer is vital. An attorney can help build a defense, negotiate settlements, and mitigate potential jail time if illegal activity is discovered.

How to Respond to an Audit Letter

Receiving an audit letter from the federal government can be an unsettling experience. However, before panicking, it is important to read the letter thoroughly to determine the agency making the request and their intentions. The main types of audit letters include the Medicare Administration Audit, Recovery Audit, Zone Program Integrity Audit, and Comprehensive Error Rate Testing.

After understanding the reason behind the audit letter, preparations should begin to address the request. Ensuring that staff members are also aware of the audit and possible visits from auditors is a crucial step. It is essential to develop a plan for responding to the request promptly, but without haste.

In some cases, audit letters may be sent directly to an employee responsible for billing. As such, staff should be aware of the possibility of receiving government audit letters. Responding to the audit letter is mandatory, but sending the correct information and mitigating any potential damage to the practice is also crucial. This is where hiring a knowledgeable healthcare audit lawyer becomes necessary to guide your practice through the process.

Audit Type Description
Medicare Administration Audit Request for medical reviews of fee-for-service claims requiring additional documentation to justify medical equipment and service purchases.
Recovery Audit Identifying and rectifying overpayments or underpayments.
Zone Program Integrity Audit Investigating suspected fraud cases by reviewing medical records, conducting site visits, and looking for patterns of improper billing.
Comprehensive Error Rate Testing Randomly reviewing statistically identified rates of improper payments.

Hiring a Healthcare Audit Investigation Lawyer: A Critical Step

Before deciding on the best approach for responding to an audit request, consult with an experienced lawyer. A legal professional will help confirm the information requested and ensure your compliance within the allotted response time. Due to the time-sensitive nature of audit letters, it’s incredibly helpful to have an established relationship with a reputable healthcare audit attorney before receiving a letter.

In conclusion, having sound legal representation can be the key to maintaining and preserving your healthcare practice during audits or investigations, ultimately enabling you to continue providing essential services for your patients.

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