Preventing a Medicare Recoupment Audit

Preventative Counsel from Houston Health Care Lawyers

Health care providers serving the Medicare population face considerable threats when their claims and billing practices are scrutinized for waste, fraud, and abuse. This includes overpayments made as a result of documentation issues, medical necessity errors, administrative mistakes, billing errors, and fraud. When unusual billing patterns and errors are identified, third party companies contracted by the Centers for Medicare & Medicaid Services (CMS), the Texas Department of Insurance (TDI), and other government agencies aggressively audit providers to determine the underlying cause, and pursue recoupment of funds.

Because recovery audits can lead to a timely and costly process, as well as potential investigations for fraud that expose providers to serious administrative, civil, and criminal penalties, preventative measures are of the utmost importance. By assessing current practices, evaluating their potential for problems, and taking steps to adjust them accordingly, health care providers of all types can effectively reduce the likelihood of audits, recoupment, and repercussions. An effective way to assess expenses is through a properly drafted and implemented compliance program.

At Hendershot Cowart P.C., our Houston health care lawyers are recognized as pre-eminent legal professionals in matters involving health and medical law. In addition to acting immediately to defend clients in audits, investigations, civil investigation demands, and recoupment proceedings that have already been initiated, we also provide comprehensive counsel to help providers establish sound and executable compliance programs that ensure compliance and reduce their exposure to consequences.

Learn more about pre-emptive counsel to prevent audits and investigations. Call (713) 909-7323 to request an initial consultation.

Pre-Emptive Counsel & Compliance

Pre-emptive measures are vital to preventing audits, the overpayment recovery process, and recoupment. This is especially true in the Medicare sector, where private contractors such as RACs can employ statistical sampling methodologies that expand overpayment sums beyond the actual claims reviewed. Just a few thousand dollars in claims can quickly become tens to hundreds of thousands in recoupment payments, and resources can be drained when providers choose to appeal aggressive overpayment decisions. Contractors also have the ability to refer cases to ZPICs and authorities such as the Department of Justice (DOJ) or Office of the Inspector General (OIG) for criminal fraud investigation.

To limit exposure to these risks, our firm focuses on the sentiment that “an ounce of prevention is worth a pound of cure,” and takes steps to pro-actively ensure sound practices and policies. These measures focus on compliance with applicable laws and regulations, along with assessment of risks providers face for possible violations. All measures are tailored to the unique circumstances of a practice and may include, among others:

  • Review of medical documents
  • Evaluation of current billing practices & service coding
  • Assessment of administrative policies
  • Analysis of data and error rate
  • Overpayment identification and subsequent protocol
  • Assessment of Stark compliance
  • Assessment of anti-kickback compliance

Due to a complex and ever-evolving Medicare system, it is common for health care providers to unknowingly commit violations. Although inadvertent, violations still create challenges, as RACs and other contractors frequently inundate providers with audit requests through which they receive contingent payment of a percentage of improper payments they identify. As such, they are aggressive in their audits and issue high numbers of adverse decisions. Although these denials can be overturned on appeal, providers incur considerable time and costs associated with appealing adverse decisions, and are better suited to investing the time needed to avoid them in the first place.

Reporting Overpayments

In addition to establishing sound billing and administrative practices, providers should also focus on creating policies for proactively identifying overpayments and promptly reporting them. By law, health care providers must report overpayments and make arrangements to return them within 60 days from when they are identified. Pro-active identification and handling of Medicare overpayments is essential to avoiding the overpayment recovery process and mitigating exposure to costly and time-consuming audits and recoupment.

Discuss Your Practice & Compliance Issues During a Consultation

While audits and appeals may be a cost of doing business in the health care space, providers can take viable steps to reduce the likelihood of an audit. From evaluating practices to ensure claims are appropriately billed, refining those practices accordingly, and establishing plans and policies to respond to any audit, providers can increase chances that they will not be targeted, and position themselves to effectively and immediately respond when an auditor does show up.

Equipped with more than 150 years of collective experience and insight accumulated through decades of representing health care providers across the state of Texas, Hendershot Cowart P.C. has the breadth of knowledge to address the concerns and compliance issues of clients on both a preventative and defensive basis. If you wish to discuss our services and learn more about preventing Medicare audits, contact us to speak with a Houston health care law attorney.


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