Kristina Giyaur, Esq.


A medical practice’s billing operations can be a significant source of risk, specifically in the form of government or private payer investigations and audits. Medicare Recovery Audit Contractors and other third parties conducting audits on behalf of private insurance plans work on a contingency basis. Not only do these entities have a legislative mandate to combat fraud and abuse, but they also have a clear financial incentive to attempt to recoup as large an amount as possible. Audit and recovery companies know that it is often easier for a physician to pay the entire amount demanded than engage in a long fight to prove that the demand was improper.

It is to no one’s surprise that audit and refund demands are riddled with inaccuracies and administrative errors. The implicit or explicit threat of either paying up or being excluded from a network looms large over all audit demands. Many providers are being caught in the wide net cast by these rogue audits. Physicians are being demoralized and legitimate practices are being damaged.

However, medical providers need not be at the mercy of audit companies. We are frequently called upon to fight illegitimate audit demands, negotiate settlements, defend clients who may be liable, and assist clients in recognizing and correcting potential areas of susceptibility to future audits and refund demands. While burdensome and often unfair, audit and refund demands must be taken seriously. Everyone in the medical profession, from the hospital systems to individual practices, have come under scrutiny. With the increase of medical audits, every medical practitioner has either already faced an audit or is likely to face one in the near future. Audit companies use ever more sophisticated methods to detect patterns, identify potential target areas, and to increase the efficiency of their recoupment operations. Providers need to have on their side a professional who can efficiently combat and address all audit-related situations.

Medical providers need to get educated on what might trigger an audit and how to minimize their risk. The most frequent targets of investigations and audits are: (1) billing for items or services not rendered or provided as claimed; (2) submitting claims for equipment, medical supplies, and services that are not reasonable and necessary; (3) double-billing, which results in duplicate payment; (4) billing for non-covered services as if covered; (5) knowing misuse of a provider identification number; (6) billing for unbundled services; (7) failing to properly use coding modifiers; (8) clustering; and (9) upcoding the level of service provided. It is important therefore to operate a practice with an eye towards minimizing audit risks, use more sophisticated methods of justifying their claims, and to preserve all documentation supporting patient diagnosis, treatment, and reimbursement demands.

Not surprisingly, Medicare and Medicaid audit and repayment demands can result in the most negative and long-ranging consequences to a healthcare provider. An overpayment received from Medicare is considered a debt owed to the federal government. Keeping an overpayment, once it is discovered, can be considered fraud under both state and federal statutes. The government has a range of civil and criminal remedies to enforce repayment demands. A Medicare or Medicaid demand must be aggressively and professionally addressed.

As your trusted healthcare advisor, we make sure that you, as a medical professional, know your rights and when the time comes we are ready to assert them on your behalf.  We are committed to staying abreast of changing payment policies and procedures, helping our clients maximize their compliance with billing and repayment obligations. Using our extensive experience and vast knowledge of the process, we regularly help physicians win audit battles and make sure that they document medical records in a way that immunizes them from further attacks.

It is imperative that physicians implement policies and procedures designed to maximize the physician’s compliance with billing and repayment obligations and minimize the risk of becoming an audit target.  Contact us so we can review your operations to minimize audit risks and to aggressively fight an audit demand on your behalf.

  • Aggressive defense in private and governmental audits using all available resources
  • Safeguarding against potential civil liability stemming from the matter
  • Preparing corrective action plans
  • Petitions to remove unfavorable information from public profile systems
  • Counseling on mitigating the harm and future compliance