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Qlarant Audits and Investigations

Our Medical Billing Experts Help Providers Avoid Payment Denials, Recoupments, and Prepayment Review

Healthcare providers that bill Medicare and Medicaid are subject to intensive oversight from private audit contractors working with the Centers for Medicare and Medicaid Services (CMS). One of these audit contractors is Qlarant. As both a Unified Program Integrity Contractor (UPIC) and the holder of CMS’s Investigations Medicare Drug Integrity Contract (I-MEDIC), Qlarant plays an outsized role in CMS’s effort to prevent fraudulent Medicare and Medicaid billings.

While fraud is a very real—and very expensive—concern, Qlarant audits and investigations targeting legitimate healthcare providers often lead to unjustified determinations of liability. As a result, for providers targeted in these audits and investigations, a proactive approach is critical. At Fortis, our medical billing experts work with Qlarant’s personnel on behalf of our clients to ensure that our clients do not face unwarranted payment denials, recoupment demands, or future prepayment review.

Understanding Qlarant’s Role in the Medicare and Medicaid Systems

As a UPIC and I-MEDIC, Qlarant shares responsibility with other CMS contractors for uncovering fraudulent billings under Medicare and Medicaid. To fulfill its duties, Qlarant conducts both audits and investigations targeting participating providers. As Qlarant explains on its website, its team “consists of former federal law enforcement officers experienced in investigative techniques that successfully uncover fraud, waste, and abuse for prosecution,” and it relies on “fifteen years of on-the-ground experience in investigation” to uncover fraudulent billings.

At Fortis, our team also consists of former federal law enforcement officers. As a result, we are prepared to go toe-to-toe with Qlarant. Whether you have received an audit letter from Qlarant or its investigators have shown up at your practice’s door, we can help you make the right decisions while dealing with Qlarant on your behalf. We provide assistance with Qlarant audits and investigations in the following states:

  • Alaska
  • American Samoa
  • Arizona
  • Arkansas
  • California
  • Colorado
  • Guam
  • Hawaii
  • Idaho
  • Louisiana
  • Mariana Islands
  • Mississippi
  • Montana
  • Nevada
  • New Mexico
  • North Dakota
  • Oklahoma
  • Oregon
  • South Dakota
  • Texas
  • Utah
  • Washington
  • Wyoming

What to Expect During a Qlarant Audit or Investigation

Qlarant moves quickly. As a result, once you find out that your practice is being targeted in an audit or investigation, it is imperative that you take action to protect your practice—and yourself—as soon as possible. In addition to relying on advanced software to review providers’ billings, Qlarant also deploys “Jump Teams” that conduct “boots-on-the-ground” investigations. At Fortis, we also rely on state-of-the-art software to assist our clients with Medicare and Medicaid billing compliance, and our medical billing experts can also be at your practice’s location on a moment’s notice. We can help ensure that Qlarant’s auditors or investigators do not exceed the scope of their authority, and we can help ensure that your practice is not unfairly penalized.

Common Allegations in Qlarant Audits and Investigations

Penalties flowing from Qlarant audits and investigations—which may include payment denials, recoupment demands, and prepayment review, among others—can arise from various allegations. Broadly speaking, these allegations will fall into one of two categories:

  • Violations of the Medicare and Medicaid billing rules
  • Improper payments between affiliated and unaffiliated providers

However, within each of these categories, fraud allegations during Qlarant audits and investigations can take numerous different forms. While allegations of upcoding, unbundling, and other coding errors are perhaps most common, allegations of paying unlawful referral fees and rebates and billing for services provided by unlicensed providers can be just as dangerous.

Regardless of the allegations that Qlarant’s auditors or investigators may raise with regard to your practice, it is critical that you not take these allegations at face value. While Qlarant’s auditors or investigators might have evidence to substantiate these allegations, they also might not. The Medicare and Medicaid billing rules are extremely complex, and they change over time. As a result, misinterpretations and misapplications are not uncommon. Likewise, the laws that govern provider relationships are extremely nuanced, and there are safe harbors and exceptions that allow relationships that seemingly violate the base language of these statutes.

Responding to a Qlarant Audit or Investigation

With this in mind, when responding to a Qlarant audit or investigation, an informed approach is critical. Under no circumstances should targeted providers assume that Qlarant’s assertions are correct. At Fortis, we work quickly and proactively on behalf of our clients to help them avoid unnecessary consequences. Our preliminary approach to responding to these audits and investigations includes:

1. Promptly Intervening in Qlarant’s Audit or Investigation

One of our first priorities in every medical billing audit and investigation we handle is intervention. We let the auditors or investigators know that we are involved—and that they need to deal with us going forward. We also impose checks to ensure that auditors and investigators are not overstepping their bounds and making unauthorized or unjustified demands for records that our clients aren’t required to disclose.

2. Analyzing the Records Qlarant has Requested

Our medical billing experts will analyze all of the records that Qlarant has requested in order to assess the scope and nature of the inquiry. Is Qlarant conducting a routine billing audit? Or, is it looking into possible “kickbacks” or illegal referral fees? These are two very different scenarios, and they require very different responses.

3. Conducting a Comprehensive Internal Audit and Risk Assessment

Once we know what Qlarant’s audit or investigation is targeting, then we will conduct a comprehensive internal audit and risk assessment. We review our clients’ compliance policies and procedures, billing practices, contracts, and other relevant documentation so that we can assess our clients’ risk and determine the best approach to responding to Qlarant’s inquiry.

Protecting Your Practice During a Qlarant Audit or Investigation

Given the risks that Qlarant audits and investigations present, it is imperative that targeted healthcare providers take steps to protect themselves. While it is possible to resolve an audit or investigation favorably, it is just as possible to face unnecessary and unwarranted consequences. With this in mind, if your practice is facing a Qlarant audit or investigation, you should:

  • Carefully Review Qlarant’s Request, But Don’t Respond Immediately – You should carefully review the communication you received from Qlarant to ensure that you understand (at least as well as possible) what Qlarant is requesting and planning to do. But, you should not respond immediately. A measured approach is required, and you should seek help from experienced professionals.
  • Preserve All Records that May Be Relevant to Qlarant’s Audit or Investigation – To avoid allegations of attempting to cover up billing violations or unlawful financial relationships, you should preserve all records that may be relevant to Qlarant’s audit or investigation. This includes not only preserving hardcopy records on-site, but also preserving emails, electronic billing files, and other relevant data.
  • Make Sure Your Personnel Don’t Speak with Qlarant’s Auditors or Investigators – You should instruct your personnel not to speak with Qlarant’s auditors or investigators. All communications with Qlarant should flow through your practice’s designated internal or external representative.
  • Consider the Need for SelfDisclosure to CMS – If your practice has improperly billed Medicare or Medicaid, it may owe a self-disclosure obligation to CMS. Our medical billing experts can determine if self-disclosure is necessary; and, if so, we can provide assistance with working with CMS as well.
  • Respond Effectively to the Audit or Investigation with a Strategic Plan – Once you have taken all of the necessary steps to prepare, which you should do as quickly as possible, you will be ready to respond effectively to Qlarant’s audit or investigation. Your response should follow a strategic plan focused on minimizing the consequences of the inquiry to the fullest extent possible.

Why Choose Fortis to Deal with Qlarant on Your Practice’s Behalf

Healthcare providers across the country rely on the medical billing experts and former federal investigators at Fortis to help them maintain compliance and avoid unnecessary liability. Here are just some of the reasons why you should choose Fortis to deal with Qlarant on your practice’s behalf:

  • Our Nationwide Practice – With experts located across the country, we assist healthcare providers nationwide with responding effectively to Qlarant audits and investigations.
  • Our SeniorLevel Team – All of our experts have senior-level experience, and you will work directly with our team of experts throughout your Qlarant audit or investigation.
  • Our Focus on Medical Billing Compliance – Medical billing compliance isn’t just what we do, it’s all we do. We know what it takes to avoid unnecessary liability for billing mistakes.
  • Our Healthcare Fraud Experience – Our experience includes not only helping providers avoid liability for allegations of healthcare fraud, but also investigating healthcare fraud for the federal government.
  • Our Commitment to Our Clients’ Success – Above all, we are committed to our clients’ success. We will use our experience to help you move forward as quickly, cost-effectively, and pain-free as possible.

Book A Free Consultation

Schedule an Initial Consultation at Fortis

If your healthcare practice is facing a Qlarant audit or investigation, we encourage you to contact us promptly for more information. Please call 866-808-4160 or get in touch online to arrange a complimentary initial consultation.