Medicare, Medicaid and Health Insurance Audits and Investigations

The Health Law Firm and its attorneys routinely represent physicians, dentists, medical groups, clinics, home health agencies, skilled nursing facilities (SNFs), group facilities for the developmentally disabled, hospitals, and other health care providers in preparing for and responding to audits and site visits for the Medicare Program, Medicaid Programs (all states), Zone Program Integrity Contractor (ZPIC) Audits, Recovery Audit Contractor (RAC) Audits, Zone Program Integrity Contractors (ZPIC) Site Visits, TRICARE Audits, and insurance company audits. We also represent health providers in administrative hearings in such matters at both the federal and state levels. We have represented healthcare providers in civil court litigation and in appeals regarding these matters as well.

It is important to retain experienced counsel at the outset. Do not attempt to respond to an audit request by yourself. There are many pitfalls associated with incomplete, improper, or untimely responses. The initial response must be accurate and include all required documents with explanations where necessary. If an overpayment amount is demanded, the correct request for review, appeals, or hearings must be properly and timely submitted to the correct place and in the proper form, with sending and receipt by the agency/auditor documented. This is not the time to skimp on legal fees or attempt to be your own attorney. In the event of an appeal, with recent changes in laws and regulations, you may be limited to whatever documents you originally submitted. In most cases, for any appeal or any hearings on overpayment demands and fines, you will need to retain the services of an experienced billing and coding consultant as an expert witness and a health care statistician as an expert witness; you must use knowledgeable, experienced experts who have testified as witnesses in these kinds of cases before.

Zone Program Integrity Contractors (ZPIC) and Recovery Audit Contractors (RAC) are private companies contracted by CMS to perform functions previously handled by Medicare regional carriers. Most recently, these have involved audits for overpayments and detection of and recovery for possible fraudulent activities. In some cases, the contractors (especially the RACs) receive a percentage of any recovery they obtain. If you receive a contact or letter about a ZPIC audit, promptly consult a healthcare attorney or a specialized Medicare audit consultant familiar with ZPIC audits.

If you receive a letter from a company claiming to be a Zone Program Integrity Contractor (ZPIC) for the Medicare Program stating it wants to audit your practice or conduct a site visit, this is a serious matter, and we would advise anyone receiving such a letter to immediately consult with healthcare counsel experienced in Medicaid audits. The states are being placed under an extreme amount of pressure to recover money for their Medicaid programs because of budget shortfalls and the federal deficit. This has resulted in an unprecedented number of Medicaid audits, Medicare audits, and audits by Zone Program Integrity Contractors (ZPIC) and Recovery Audit Contractors (RAC) seeking to recover money from physicians, dentists, and other health providers for the state and federal government.

We have a process we follow to ensure that complete documentation for all care that has been billed to such programs is provided and that any “hot” issues that we know are being scrutinized by auditors are properly addressed. Because of the extrapolation formulas that are used by government auditors, each dollar that is disallowed by the auditor can equate to many times the amount that you are determined to owe back. For example, if a claim for a procedure that you were paid $100 to perform is disallowed, this may be extrapolated to a $5,000 repayment using a statistical formula. In addition, you can be assessed fines (for failing to comply with documentation requirements) and the costs of the audit and experts’ reviews as well. Because of recent changes in Florida laws, the amounts disallowed must be paid back to AHCA within thirty (30) days, even if the provider requests a hearing to challenge the findings. If the audit is wrong and you do not owe the money the agency says, it is imperative that a formal administrative hearing be properly requested promptly so that you have the proper opportunity to prove your entitlement to the money.