Health Care Professionals: Are You A Target of Medicare Audits? Follow These Tips to Protect Yourself and Your Practice

Wednesday, January 27, 2016
By George F. Indest III, J.D., M.P.A., LL.M., Board Certified by The Florida Bar in Health Law

Health care professionals in Florida who serve Medicare patients are at a higher risk for audits than anywhere else in the country. Unfortunately, Florida seems to have become synonymous with health care fraud. At The Health Law Firm, we have been contacted and retained by many health care professionals that have become the subjects of Medicare audits. If you find yourself or your health care facility or practice the target of a Medicare audit, there are several things you need to know to help you get through the process.


How Do You Know If You Are Being Targeted?

If you find that you are the subject of a Medicare audit, it will usually begin with receiving an initial audit request. This request is to notify the recipient that it is the subject of an audit and sometimes will not identify the reason for the audit. What it will identify however, is a list of names and dates of service for which the auditors need to see copies of medical records and other documentation.

If it is a short list, usually from one to five patients, then this is probably just a "probe" audit.  You are being probed to see if there are grounds to do a much more extensive audit, or even to initiate a fraud investigation.  The lowest number of records we have ever seen on the audit of a single individual Medicare provider (not a company or a group) was one record. The highest number was 270 records.


Submit Complete, Legible Copies of the Records Requested.

I am mentioning this tip first, because it is probably the most important one in the audit process. The biggest mistake the subject of an audit can make is to hastily copy and send only portions of the available records, instead of the complete record. By complete record, we mean every note, order, referral, consultation, x-ray report, prescription, initial history and physical, and all prior records form anyone else that are within your record.

Review the billings (claims or CMS 1500s) submitted. Check to make sure you have the appropriate medical record entries to support every claim. If you are missing any, search to attempt top locate them. They could be misfiled. For any missing or incorrect records or entries, insert a separate typed statement or letter, contemporaneously dated, that explains the discrepancy. If you have any handwritten notes or orders that are illegible or too light to read, you must obtain a typed transcription, appropriately labeled and contemporaneously dated, that transcribes the entry or order.

It is important to compile a thorough, completely legible set of records, well organized and labeled, to provide to the auditor for all services billed. Explain any missing records or entries.  If you submitted a claim for a patient visit, and cannot find the corresponding record entry, insert a copy of the patient sign in sheet along with an explanation of the missing record.  For any unusual tests, procedures or billings, insert or attach an explanation (you can also include medical literature, clinical guidelines and local coverage determinations or LCDs).

To read more on this step in the audit process, click here to read one of my past blogs.

Once you have submitted records, these will be reviewed by the auditor and you will later be contacted with the results.


Responding To An Initial Audit Request.

The following are some additional tips that health care providers should follow in order to obtain the best results when you respond to an audit request:

1.  Read the audit letter carefully and provide all the information requested. It is much safer to send too much documentation than too little.
    
2.  Have a compliance officer, experienced consultant or experienced health attorney compile records and handle any follow-up requests.
    
3.  Pay attention to details and deadlines. If you cannot submit documentation before the deadline, telephone and request an extension of time, following up with a letter documenting the request.

4.  Number all pages of the documents that are submitted.
5.  Be sure to make and save a complete copy of everything submitted.

6.  When sending in the documentation, be sure to use a reliable carrier, that provides package tracking and delivery confirmation to ensure it will arrive before the deadline and you can prove it was sent and received.
For more details on these helpful tips, click here to read one of my past blogs.


Responding to Medicare Audits Can Be An Arduous Task.

Even on a routine audit, given the consequences, we recommend you immediately retain the services of an experienced health attorney to guide you through the audit process, communicate with auditors and to be prepared if it is necessary to challenge the audit.


Contact Health Law Attorneys Experienced in Handling Medicaid Audits, Investigations and other Legal Proceedings.

The Health Law Firm’s attorneys routinely represent physicians, dentists, orthodontists, medical groups, clinics, pharmacies, assisted living facilities (AFLs), home health care agencies, nursing homes, group homes and other healthcare providers in Medicaid and Medicare investigations, audits and recovery actions.

To contact The Health Law Firm please call (407) 331-6620 or (850) 439-1001 and visit our website at www.TheHealthLawFirm.com.


Comments?

Have you ever been a target of a Medicare audit? If so, how did you respond or prepare? Please leave any thoughtful comments below.


Sources:

Indest, George. “19 Tips to Prepare You For a Medicare Audit and Site Visit.” Medical Economics. (December 10, 2012). Web.

“Conducting a Self Audit: A Guide for Physicians and Other Health Care Professionals.” Centers for Medicare and Medicaid Services. (January 26, 2016). Web.


About the Author: George F. Indest III, J.D., M.P.A., LL.M., is Board Certified by The Florida Bar in Health Law. He is the President and Managing Partner of The Health Law Firm, which has a national practice. Its main office is in the Orlando, Florida, area. www.TheHealthLawFirm.com The Health Law Firm, 1101 Douglas Ave., Altamonte Springs, FL 32714, Phone: (407) 331-6620.


KeyWords: Medicare fraud, Medicare fraud investigation, Florida Medicare audit, Florida Medicare Program, initial audit request, Medicare claims, overbilling, overpayments, Department of Health and Human Services (HHS), Office of Inspector General (OIG), defense attorney, defense lawyer, Medicare fraud defense attorney, Medicare fraud defense lawyer, Florida health law attorney, The Health Law Firm

"The Health Law Firm" is a registered fictitious business name of George F. Indest III, P.A. - The Health Law Firm, a Florida professional service corporation, since 1999.
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1/27/2016

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