Audit/Refund and Demand Attorneys
At the offices of Abrams Fensterman, LLP, when it comes to insurance audits, our goal is to evaluate and minimize any potential liability, establish a defense when liability may exist, and assist the client in correcting any potential areas of vulnerability to future audits and repayment demands. Our health law attorneys have established a multi-tiered approach to medical record and billing audits received by our clients, keeping in mind that there is no “generic” or “routine” audit, as each physician or practice has its own unique attributes and qualities. Accordingly, we analyze and prepare each case based on its own characteristics.
The first step in our process is to review and categorize the medical record/audit demand received by the client. There are several different types of demands that a client may receive, including demands which are purported to be issued solely for data collection purposes. This evaluation includes an analysis as to whether the audit involves only private carrier funds or whether it includes government funds distributed through the Medicare or Medicaid programs; whether there is an indication that the carrier is looking into issues of fraud or abusive billing and whether the client is a participating provider with the carrier. All of the aforementioned, as well as a multitude of other details, are evaluated so as to formulate an initial strategy to comply with the demand for medical records if required and defend any potential repayment demand.
The second step in our process commences if its determined the medical records are going to be provided. At this point we work in conjunction with the client to assemble the requested medical records and perform an “in house” preliminary assessment. In addition to experienced and knowledgeable attorneys from our Insurance and Audit Department, Abrams Fensterman, LLP has several staff attorneys and personnel who are licensed medical professionals. When necessary, these medical professionals participate in our review. Further, Abrams and Fensterman, LLP maintains professional relationships with multiple certified professional coding companies that may be utilized. In general, clients are recommended to have their records evaluated by one of our coding professionals for both strategic and prophylactic reasons.
When all of the aforementioned is completed, an analysis on the substantive claims and coding issues is performed, as well as a statutory analysis to determine whether the client may have procedural defenses limiting their exposure to a repayment demand in the event that it is determined the client may have exposure, a defensive strategy is created with the assistance of the client and any professional coders utilized, and a strategy of negotiation is implemented. Further, the reasons for the liability are evaluated and recommendations provided so that corrections and changes may be implemented by the client in order to reduce the risk of exposure in the event of any future record demands and audits.
At Abrams Fensterman, LLP we believe that this comprehensive approach to the audit process not only provides the best possible results, it also places clients in the best possible defensive position in the event additional record/audit demands are received in the future from the same or different carriers.