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Managing Post-Payment Audits for Practitioners and Institutions

Guidance for dealing with insurance company audits and demands

In the past, insurers approved the services rendered before paying for other providers. Today, most insurers reimburse provider claims first, and only then “audit” the claim to determine if the services, billing and coding were appropriate. As a result, health care providers have seen a dramatic increase in refund requests and overpayment demands from both Medicare and commercial payers. Buttaci Leardi & Werner, LLC offers representation in overpayment disputes with both governmental agencies and private insurance carriers.

Our experience is such that we routinely counsel providers (and their attorneys) throughout the country on overpayment disputes involving allegations of:

  • Improper billing, coding and claim submissions
  • Inadequate documentation
  • Medical necessity
  • Experimental or investigational procedures
  • Improper business structures
  • Self-referrals

What happens in the audit process?

The first step in the audit process may be a demand for patient records or a demand for repayment. Unfortunately, there is no generic or routine audit — each practitioner and practice has its own specific attributes, qualities and patients. At Buttaci Leardi & Werner, once our client has been notified of a demand for medical records or a demand for an audit, we start by determining what the insurance company is requesting — immediate repayment or patient charts for review, data collection purposes or another reason. We also analyze other factors, including:

  • Are you a participating provider with the demanding insurance carrier?
  • Are there federal funds involved from Medicare or Medicaid?
  • Are there private insurance funds involved, such as payment by Aetna or United HealthCare?
  • Is the carrier seeking information on fraud or abuse issues?

Depending on the answers to these and other questions, our lawyers work with you to develop a compliance and response strategy. This may include assessing the medical records demanded, working with professional medical coding companies to examine the submitted coding and alleged improper billing, and reviewing any defenses to the repayment demand. If it does appear at that point that there will likely be some exposure, we help develop a strategy for defense, prepare for negotiation and create a risk management and risk reduction system for future billing. Our goal is to get you the best possible results and to ensure that each of our clients is in the best possible position for any future post-payment audits.

Learn more about our audit defense practice

To learn more about how Buttaci Leardi & Werner can assist you with post-payment audits, please contact us online or call us at 609.297.5942.