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Healthcare Audits

Are You Facing a Healthcare Audit? Our Former Federal Agents Can Help

Dealing with audits is part of doing business for healthcare providers, pharmacies, healthcare organizations, and other entities that bill Medicare, Medicaid, and other public and private payors. If you are facing a healthcare audit, it is important to know what you can expect during the healthcare auditing process. This will allow you to make informed decisions along the way, and it will help mitigate the risk of unwarranted recoupments, payment denials, and other penalties uncovered during a comprehensive audit.

At Fortis, we assist providers and other entities with all types of healthcare audits. Whether you or your healthcare organization have received an audit notice from a CMS contractor or a private insurer such as Aetna, Cigna, or United HealthCare, we can guide you step-by-step. Our former federal agents can advise you while communicating with auditors on your behalf, and we can use our experience and expertise to identify any flaws or overreaching during the audit process.

The Advice You Need When Facing a Healthcare Audit

Healthcare audits present substantial risks for providers and other entities. Audited entities frequently face recoupments, and sometimes the amount they owe is more than they can afford to pay. Audits can lead to denial of pending claims as well, and this can disrupt entities’ cash flow—potentially causing them to miss payroll and fall behind on other bills.

Unfavorable audit determinations can also have consequences for the future. For example, along with recoupments and payment denials, auditors also have the authority to impose prepayment review for future billings. Not only can this lead to an increased denial rate, but it can also delay payments by several months. When you rely on your payments to meet your practice’s or business’s monthly obligations, this can have catastrophic effects.

But, the worst-case scenario is that a healthcare audit leads to a criminal healthcare fraud investigation. All healthcare auditors—under federal benefit programs and with private insurers—can refer providers and other entities to the U.S. Department of Health and Human Services Office of Inspector General (HHS OIG) when the federal government audits uncover alleged evidence of intentional fraud. HHS OIG investigations can lead to criminal prosecution, which can in turn lead to fines and imprisonment.

In all scenarios, healthcare audits require an informed, strategic, and proactive approach by the healthcare provider. At Fortis, we know what it takes to protect our clients during the audit process.

Types of Healthcare Audits We Handle

We handle all types of healthcare audits for providers, pharmacies, and other entities. This includes audits conducted by fee-for-service contractors working with CMS, audits under non-CMS federal healthcare benefit programs, and audits conducted by private insurance companies. Some examples include:

  • Aetna audits
  • Anthem audits
  • Cigna audits
  • Department of Labor (DOL) audits
  • Health Resources and Services Administration (HRSA) audits
  • Humana audits
  • Medicare audits (including MAC, RAC, UPIC, and ZPIC audits)
  • Medicaid audits (including MFCU audits)
  • Qlarant audits
  • Tricare audits
  • United HealthCare audits

Again, these are just examples. If you are facing a healthcare audit from any public or private payor, we can help ensure that you do not face unnecessary negative outcomes. However, it is important that we are able to intervene as soon as possible, so we encourage you to contact us promptly to get started.

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What To Expect During a Healthcare Audit

If you’ve been through a healthcare audit before, you already have a general idea of what you can expect. While different auditors have different processes and procedures, the major steps in medical audits tend to be more or less the same.

If this is your first healthcare audit, understanding what you can expect will be extremely important. While audits are common, facing an audit is far from routine, and being unprepared can leave your practice or business at risk for unnecessary penalties.

Broadly, the healthcare audit process can be divided into three stages:

Stage #1: Pre-Audit Preparations (and Remote Billing Review)

By the time you learn that your practice or business is being audited, a portion of the audit has almost certainly already been completed. Auditors regularly conduct remote billing reviews, and these reviews can trigger additional scrutiny if they raise concerns about upcoding, unbundling, or other billing practices violations.

As soon as you learn about an impending audit, it is important to begin your preparations. At Fortis, we work with our clients to ensure that they are fully prepared. This includes not only identifying all relevant records, but also conducting a confidential review of these records to assess the risks (if any) that the audit presents.

Stage #2: In-Depth Review of Billing Records and Other Files

During the audit, auditors will scrutinize your practice’s or business’s billing records, patient medical records, compliance documents, clinical documentation, medical documentation, contracts, and other relevant files. They may also seek to interview members of your billing department and other personnel.

It is extremely important that you do not grant auditors any access that is not strictly required. It is equally important that you oversee their auditing practices—as mistakes can (and often do) lead to unjustified recoupments and other penalties. By managing the audit on your behalf, our team can help ensure that you do not face unnecessary and unwarranted consequences.

Stage #3: Audit Determination and Next Steps

After completing their review, the auditors will make a determination of liability. This is the stage at which you will learn if they intend to demand recoupments, deny pending claims, impose prepayment review, or take any other adverse action. It is also the stage at which you will need to determine your next steps. If the outcome of the audit is fair, then your next step may simply be getting back to business as usual. However, if the outcome of the audit is unfair, you may need to consider filing an appeal.

What To Do When Facing a Healthcare Audit

Given the risks involved, when facing a healthcare audit, there are some steps you should take promptly. To give yourself the best chance of a favorable outcome, you should:

  • Preserve all relevant records. Deleting relevant records, even inadvertently, can raise additional questions and lead to additional scrutiny.
  • Conduct a billing compliance assessment. When facing a healthcare audit, knowing what (if anything) the auditors may find will allow you to make informed decisions.
  • Engage a team of professionals to manage the audit process. Due to the complexities of demonstrating billing compliance and the importance of avoiding unnecessary consequences, it is critical to have an experienced team of professionals on your side.

Of course, these are not all of the steps involved in preparing for a healthcare audit. When you schedule a free initial consultation at Fortis, one of our former federal agents will explain everything you need to know.

FAQs: Avoiding Unnecessary Negative Outcomes During a Healthcare Audit

How Do I Prepare for a Healthcare Audit?

There are several steps involved in preparing for a healthcare audit. Along with preserving all relevant records and conducting an internal billing compliance assessment, you will also need to have a strategy in place for communicating with auditors and managing the audit process. The team at Fortis can help. Conducting an internal audit of your current practices can help uncover any areas in need of improvement. Internal audits can be a great first step in fortifying your billing practices.

What Do Healthcare Auditors Do?

Healthcare auditors review participating providers’ and other entities’ internal records to assess billing compliance. After conducting this assessment, they can (and do) impose penalties for noncompliance. These penalties can include recoupments, denial of pending claims, and prepayment review, among others. While these penalties will be warranted in some cases, mistakes are common. As a result, it is critical that targeted entities play an active role in the audit process.

Do I Need to Engage a Consulting Firm for a Healthcare Audit?

Engaging a consulting firm for a healthcare audit is strongly recommended. Auditors focus solely on uncovering billing violations, and they are incentivized to impose recoupments and other penalties. To level the playing field, targeted providers and other entities need a team of experienced professionals on their side. At Fortis, our former federal agents have extensive experience on both sides of healthcare audits, and we can use our experience to protect you. An outside firm can conduct an external audit and give an unbiased review of your practices to show areas in need of quality improvement measures. External audits can be very insightful when facing a health care audit.

What Are the Potential Outcomes of a Healthcare Audit?

The potential outcomes of healthcare audits range from a finding of total compliance to a finding of substantial noncompliance. In the latter scenario, consequences can range from recoupments and other payor-imposed penalties to criminal prosecution.

What Should I Do During a Healthcare Audit if My Practice or Business has a High Error Rate?

If your practice or business has a high error rate, this is an issue that you will need to address proactively as early in the audit process as possible. Not only having a high error rate, but knowing that you have a high error rate, can significantly increase the risks involved in facing a healthcare audit. Once we learn more about your situation, we can advise you regarding how best to approach your impending audit.

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Get Started with a Free Healthcare Audit Consultation at Fortis

To speak with a former federal agent at Fortis about your upcoming healthcare audit, contact us today. Call 866-808-4160 or send us a message online to schedule a free healthcare audit consultation.

Additional Information About Healthcare Audits