![]() Under the Medicare billing regulations and CMS’s “fee-for-service” audit rules, findings of improper billings can lead to: Speaking of consequences, the consequences of a Medicare audit can be significant. The Consequences of a Medicare Audit Can Be Significant Instead, they need to scrutinize auditors’ methods and conclusions, and they need to proactively address any issues that have the potential to lead to unwarranted or unnecessary consequences. Additionally, CMS’s “fee-for-service” audit program incentivizes private contractors to pursue maximum recoupments, and this unfortunately also leads to unjustified audit results in some cases.Īll of this means that healthcare providers and business owners cannot trust the audit process-and they cannot simply allow a Medicare audit to run its course. The unfortunate reality is that even many auditors do not have a comprehensive and accurate understanding of the extraordinarily complex Medicare billing rules and regulations. While auditing plays an important role in preventing fraud, waste, and abuse in the Medicare system, it also frequently leads to unwarranted consequences for legitimate healthcare providers and other businesses. Medicare Audits Can (and Frequently Do) Lead to Unwarranted Consequences ![]() Instead, providers and businesses that are facing audits should take a proactive approach to their defense, and they should engage a team of expert Medicare billing and audit defense consultants to deal with the audit for them. A Medicare audit should not be a unilateral process. This invites a host of problems, and it can lead to scrutiny of billings (and other practices) that shouldn’t be subject to review. Too often, healthcare providers and business owners make the mistake of allowing auditors to examine their billing records without oversight. A Medicare Audit Should Not Be a Unilateral Process So, identifying the entity that is auditing your practice or business is the first step toward an effective defense. If the OIG (or another federal agency) is conducting the audit, this requires a particular approach as well. This means that these companies have a financial incentive to uncover overpayments only-and this significantly influences the audit process.īut, while dealing with a MAC, RAC, or UPIC presents some unique challenges, so does dealing with the federal government. The Centers for Medicare and Medicaid Services (CMS) engage private companies to conduct Medicare audits on a “fee-for-service” basis. Department of Health and Human Services’ Office of Inspector General (OIG) conduct Medicare audits, so do private contractors. You Need to Know What Entity is Conducting the Audit Here are some important facts to know if your healthcare practice or business is facing a Medicare audit: 1. When engaged for Medicare audit defense, we walk physicians, pharmacists, executives, and business owners through everything they need to know, and then we get to work quickly putting the framework in place so we can execute an efficient and strategic defense. Healthcare providers and business owners need to have a clear understanding of the audit process, the potential outcomes, and their legal rights. Successfully defending against a Medicare audit requires an informed approach. Medicare Audit Defense: What Healthcare Providers and Business Owners Need to Know We use our government experience to our clients’ advantage, and we have a proven track record of helping providers and other businesses avoid unnecessary liability and other consequences during (and after) the audit process. As a result of our consultants’ vast government experience, we are extremely well-versed in the rules, process, and procedures that govern Medicare audits. Our former OIG healthcare fraud investigators provide Medicare audit defense services for physician practices, pharmacies, hospitals, clinics, laboratories, and other healthcare entities nationwide. Secret Service (ret.) Former OIG Healthcare Fraud Investigators with Proven Results in Medicare Audit Defense
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