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Lowther | Walker’s healthcare audit defense lawyers defend healthcare professionals against criminal penalties during Medicare and Medicaid audits. Our attorneys prepare healthcare professionals and their medical teams for UPIC, MAC audits, and other government audits and provide representation in communications with auditors. Through our diligent analytical approach, we help medical providers identify and resolve instances of:
Proactively book your free, confidential consultation online or call (404) 496-4052 to discuss our healthcare audit defense services.
Our team can respond within minutes around the clock to protect your practice and preserve your reputation.
No-obligation. Fully confidential.
Call Us Today: (404) 496-4052
By proactively contacting Lowther | Walker, you can avoid audit consequences ranging from exclusion from your insurance network to criminal prosecution for healthcare fraud. We’ll work tirelessly to defend your practice and your future within the industry.
Our team has decades of experience in healthcare compliance and has demonstrated its industry expertise by successfully defending a client in the highest-value healthcare fraud case the DOJ has ever prosecuted.
Lowther | Walker provides aggressive audit defense and representation for physicians, dentists, psychiatrists, and other healthcare professionals during MAC, RAC, UPIC, and other federal audits. Turn to our healthcare audit lawyers for:
Our proven experience defending healthcare practitioners and preventing audits from escalating into criminal proceedings is why so many professionals across the country call Lowther | Walker when they receive a notice from UPIC or MAC auditors.
Your healthcare fraud audit lawyers should be responsive and have the resources to respond promptly to documentation requests and potential investigator questions. Lowther | Walker’s team includes seasoned defenders of healthcare professionals offering 24/7 audit response services to ensure always-available legal guidance and support.
Our lawyers travel the country to represent healthcare professionals facing healthcare audits. Over our decades defending healthcare professionals, we’ve traveled to every state and represented some of the largest healthcare companies and prominent nationwide providers.
Investigation terminated; no prosecution. DOJ notified our client, the CEO of a major hospital network, that he was the target of a multi-million-dollar healthcare fraud investigation related to “Medicare upcoding” that the FBI and HHS-OIG […]
The FBI and the HHS-OIG investigated our client for Health Care Fraud based on the client’s submitting over $7 million in alleged false claims to Medicare. The Government indicted our client on Conspiracy to commit […]
HHS-OIG investigated our client for Healthcare Fraud and Aggravated Identity Theft based on the client’s allegedly participating in a “telemedicine” kickback scheme that defrauded Medicare of approximately $30 million in reimbursements for not-medically-necessary durable medical […]
A private insurance company discovered that our client, a dentist, fraudulently billed it, various other insurance companies, and federal health care benefit programs for approximately $400,000 of services that our client did not provide. We […]
The Department of Justice’s Criminal Division, Fraud Section charged our client and nine other individuals in a $1.4 Billion health care fraud, wire fraud, and money laundering conspiracy (the largest health care fraud case that […]
Investigation terminated; no prosecution. DOJ notified our client, the CEO of a major hospital network, that he was the target of a multi-million-dollar healthcare fraud investigation related to “Medicare upcoding” that the FBI and HHS-OIG […]
The FBI and the HHS-OIG investigated our client for Health Care Fraud based on the client’s submitting over $7 million in alleged false claims to Medicare. The Government indicted our client on Conspiracy to commit […]
HHS-OIG investigated our client for Healthcare Fraud and Aggravated Identity Theft based on the client’s allegedly participating in a “telemedicine” kickback scheme that defrauded Medicare of approximately $30 million in reimbursements for not-medically-necessary durable medical […]
A private insurance company discovered that our client, a dentist, fraudulently billed it, various other insurance companies, and federal health care benefit programs for approximately $400,000 of services that our client did not provide. We […]
The Department of Justice’s Criminal Division, Fraud Section charged our client and nine other individuals in a $1.4 Billion health care fraud, wire fraud, and money laundering conspiracy (the largest health care fraud case that […]
A healthcare audit is a systematic review of your medical records, billing practices, and documentation to ensure that the services you billed to Medicare or Medicaid were actually provided, medically necessary, and properly documented.
The following authorities conduct healthcare audits on behalf of the federal government
Each organization has different authority levels and focuses, but all are designed to protect Medicare and Medicaid from improper payments.
Healthcare audit defense lawyers can identify and neutralize specific red flags in your documentation that might otherwise cause a routine civil audit by the Centers for Medicare and Medicaid Services to be referred to the OIG or FBI for criminal prosecution. The Department of Health and Human Services OIG and CMS auditors are trained to look for patterns of fraud. Without legal intervention to contextualize errors, a simple administrative review can easily become a career-ending criminal case for medical providers.
Legal counsel can aggressively challenge the auditor’s extrapolation methods and statistical sampling to reduce the total repayment demand significantly. Auditors often take a small sample of errors and mathematically project them across years of claims to demand massive refunds; an attorney knows the specific administrative laws and regulations required to fight these calculations and narrow the audit’s scope.
An attorney acts as a shield between you and the auditors, ensuring you do not inadvertently waive privilege or make admitting statements that could be used against you. Providers often try to “explain” their way out of an audit. Still, innocent explanations for billing actions can be twisted into admissions of negligence if not carefully managed by counsel.
Healthcare providers can overestimate their ability to navigate the auditor’s probing of their accounting and health insurance billing practices. As a result, their practice may be shut down, their license revoked, and they may face a prison sentence for healthcare fraud.
The federal agency’s decision to begin an audit may be due to a computer model suggesting an error in your data. Or it could be the result of a patient complaint. But once auditors have access to your healthcare company’s data, you’re at their mercy unless you hire a skilled healthcare audit defense lawyer such as Lowther | Walker.
Whether you’re a family dental practice owner or an urgent care provider with a large staff across multiple properties, contact Lowther | Walker for healthcare audit defense and compliance guidance.
Learning the incremental phases of a healthcare audit can prepare your team for the road ahead. The steps of the healthcare audit process include:
Audits may originate from a complaint of overbilling or a computer-generated analysis of your submitted paperwork. Federal agencies deploy sophisticated analytical tools to review providers within government programs and pinpoint those who may be outliers within their industry and region.
Once the initial data review of patient reports or internal data is complete, agency teams determine whether the information is provided to auditors or fraud investigators to further the investigation.
Suspicions of fraud will immediately trigger an audit by an investigator who may then recommend action, such as payment suspensions, to the Department of Justice. If your organization receives an audit request signed by a fraud investigator, you may wish to begin building your legal defense by hiring a healthcare fraud attorney. In cases where data auditors identify issues such as billing irregularities, the next step will be to request records.
Here, the auditors will request specific patient records. The record request may arrive by mail or through the record management system. Upon receiving the request, you should contact a healthcare audit law firm to analyze the request, review your internal data, and handle any communications with auditors and federal investigators.
After your team complies with the record request from the DOJ’s auditing team, the record goes to a medical specialist within the agency for more intensive analysis. You can expect this analysis to take several months as the government’s forensic team reviews the data.
The result of the review will be provided to you by the lead auditor. They will decide whether to unflag you and allow you to continue with your current billing practices, recoup billed amounts to the payor, or recommend referral to law enforcement officials at the DOJ and DEA for criminal investigation.
A demand for overpayment is not the final word. When a MAC, RAC, or UPIC demands recoupments, healthcare providers have the right to challenge the findings through the administrative appeals process. Missing a deadline or failing to submit the correct procedural documentation can forfeit your right to appeal. Our attorneys aggressively represent providers through all five levels of the Medicare appeals process:
Level 1: Redetermination by a MAC. We file a structured rebuttal to the initial demand, fighting to stop recoupment efforts before they disrupt your cash flow.
Level 2: Reconsideration by a QIC. If the initial decision is unfavorable, we escalate the appeal to a Qualified Independent Contractor, utilizing independent medical experts to validate your coding and billing.
Level 3: Administrative Law Judge (ALJ) Hearing. This is often the most critical stage. We present a robust evidentiary defense, cross-examine auditors, and challenge flawed audit methodologies before an independent judge.
Level 4: Medicare Appeals Council. If the ALJ’s decision contains legal or factual errors, we escalate the case to the Council in Washington, D.C., for a comprehensive review.
Level 5: Federal District Court. When administrative remedies are exhausted, our experienced federal litigators are prepared to file suit in federal court to protect your practice and your license.
Medicare Administrative Contractors (MACs) use TPE audits under the guise of education. Providers are subjected to up to three rounds of prepayment or post-payment reviews targeting specific billing codes.
Failing a TPE audit round can result in 100% prepayment review, massive overpayment demands, referral to the OIG, or suspension of your Medicare billing privileges.
Our defense strategy engages immediately. We audit the disputed claims alongside clinical experts, correct systemic billing errors, and formulate a direct response to the MAC to ensure you pass the probe and avoid fatal escalation.
Unlike targeted audits, CERT audits are entirely random, designed by the CMS to measure the overall accuracy of the Medicare fee-for-service program. However, if your practice is selected and the CERT contractor identifies a high error rate in your claims, it serves as a red flag. A poor CERT review frequently triggers highly invasive, targeted audits from RACs or UPICs.
Our lawyers step in to handle CERT documentation requests, ensuring the auditors receive exactly what they need to satisfy the audit and keep your practice off the CMS radar.
When auditors find a few coding errors, they rarely stop there. Instead, they use statistical sampling to project a small error rate across thousands of your claims, turning a $5,000 billing mistake into a $5 million recoupment demand.
Extrapolation is the most dangerous tool in the government’s arsenal, but it is highly vulnerable to legal challenge. Our firm attacks the mathematical and procedural validity of the auditor’s work. We collaborate with leading statisticians and data experts to dismantle the government’s case by proving:
The sample size was statistically invalid or improperly drawn.
The universe of claims was incorrectly defined.
The extrapolation methodology violated the Medicare Program Integrity Manual.
By invalidating the statistical sample, we can frequently reduce a multi-million dollar ruinous demand to the actual, verifiable overpayment amount, which safeguards the practice and protects the provider’s livelihood.
When facing a Medicaid audit, healthcare facilities must navigate rigorous scrutiny from State Medicaid Fraud Control Units (MFCUs) and the Centers for Medicare & Medicaid Services (CMS). These investigations target alleged upcoding, medical necessity discrepancies, and potential violations of the False Claims Act. Without proper documentation and swift legal intervention, providers risk severe administrative sanctions, extrapolated recoupment demands, or direct referrals to the Office of Inspector General (OIG) for criminal prosecution.
We defend Medicaid providers by
Conducting confidential, parallel forensic audits of patient billing data to identify exposure scope and protect favorable evidence before state investigative agencies can secure it.
Immediately routing all agent inquiries through the law office to prevent staff from making self-incriminating statements to MFCU or state Medicaid investigators.
Engaging prosecutors and auditors early to present exculpatory evidence, aiming to downgrade criminal targets to civil administrative issues before formal charges are ever filed.
Medicare audits initiated by Medicare Administrative Contractors (MACs) on behalf of the Centers for Medicare & Medicaid Services (CMS) can quickly disrupt practice cash flow through sudden prepayment reviews. The complex appeals process relies on a rigid five-level system, beginning with a Level 1 Redetermination and potentially escalating to an Administrative Law Judge (ALJ) hearing or Federal District Court. If CMS auditors suspect systemic billing fraud or violations of the Anti-Kickback Statute, this civil inquiry can easily transform into a devastating Department of Justice (DOJ) investigation.
Our lawyers will
Aggressively represent medical providers through all five levels of the Medicare appeals process, from MAC redeterminations to federal court litigation.
Deploy a network of independent medical and statistical experts to validate the medical necessity of care and scientifically disprove flawed government damage calculations.
Challenge auditor access and methodology to ensure strict compliance with CMS regulations, preventing overreach and faulty conclusions based on limited evidence.
Unified Program Integrity Contractors (UPIC) execute the federal audits with the most serious potential penalties, explicitly tasked with investigating suspected fraud, waste, and abuse (FWA) across both Medicare and Medicaid. Unlike routine administrative reviews, UPIC audits frequently trigger immediate payment suspensions and direct criminal referrals to the Department of Justice (DOJ) or the Federal Bureau of Investigation (FBI). Providers facing these aggressive inquiries run the critical risk of permanent exclusion from federal healthcare networks and subsequent criminal indictments.
The Lowther | Walker UPIC defense team:
Provides 24/7 urgent response services to immediately intervene in UPIC investigations, ensuring healthcare practices are shielded from unchecked auditor access.
Identifies and neutralizes specific documentation red flags that might otherwise trigger a criminal referral to the OIG or FBI.
Challenges the extrapolation methods and statistical sampling models used by UPIC investigators to reduce or eliminate alleged overpayment demands.
Civilian medical providers treating military personnel are subject to strict oversight from the Defense Health Agency (DHA) during targeted TRICARE audits. Federal investigators scrutinize inpatient admissions and outpatient services for precise adherence to the TRICARE Operations Manual (TOM) and the TRICARE Reimbursement Manual (TRM). If an initial audit uncovers systemic non-compliance, it can rapidly escalate into a high-stakes formal investigation led by the Defense Criminal Investigative Service (DCIS) or the Department of Defense (DoD) OIG.
If you’re facing a Tricare audit, our team:
Immediately notifies TRICARE regional contractors and federal investigators that all communications must be routed exclusively through your defense attorney.
Monitors auditing practices to ensure strict adherence to TOM and TRM guidelines when sampling claims, calculating payments, and establishing error rates.
Represents practices during Program Integrity (PI) audits to address clinical documentation concerns before they escalate into formal administrative sanctions or DCIS investigations.
Recovery Audit Contractors (RAC) are specialized entities retained by the Centers for Medicare & Medicaid Services (CMS) to execute post-payment reviews and identify systemic overpayments. Because RACs operate strictly on a contingency fee basis, earning a percentage of the funds they recover, they are financially incentivized to hunt for billing errors and push for aggressive recoupments. These audits rely on automated data mining and complex algorithms to flag suspected anomalies in Current Procedural Terminology and International Classification of Diseases coding.
Our attorneys proactively defend providers under RAC audits by
Analyzing the data mining algorithms and statistical sampling techniques used by RACs to dispute unsupported conclusions and calculation errors.
Formulating a cohesive, evidence-based rebuttal to RAC audit findings by presenting robust documentation that supports medical necessity and proper coding.
Proactively negotiating and litigating against RAC overpayment demands to protect clinic revenue and preserve the provider’s professional reputation.
Our seasoned lawyers will diligently work to defend you, your healthcare business, and your team before, during, and after healthcare audits. We’re here 24/7 to answer your questions and help you navigate the audit process successfully.
Call Lowther | Walker via (404) 496-4052 and book a free, no-obligation consultation with a healthcare audit attorney.
No-obligation. Fully confidential.
Call Us Today: (404) 496-4052
Your healthcare audit lawyer can help guide you regarding providing auditors document access. Your lawyer can help ensure that the auditors only access the documentation subject to their request. They can also ensure your communication during the audit is precise, limiting the potential for errors of fact.
Through our work with physicians, dentists, psychologists, optometrists, and other medical providers, our lawyers help clients facing a wide range of auditor allegations, including:
We also have the experience and resources to fight back against auditor overreach and oversights, including:
A UPIC audit by Unified Program Integrity Contractors (UPIC) involves reviewing Medicare program providers’ patient records and establishing Medicare billing practices. The goal of a UPIC audit is to detect and prevent fraud, waste, and abuse in Medicare and Medicaid programs. UPIC audits can result in criminal charges, and the audit process often begins with little warning to the provider or their team. The significant penalties and the sudden nature of a UPIC audit require providers to consult seasoned healthcare audit lawyers, such as the Lowther | Walker team, to help mitigate penalties and safeguard their professional reputation.
Yes, in addition to criminal enforcement action, there is the potential for you and other team members to be referred to the professional licensing board for failures during a healthcare audit. Upon referral to the licensing board, the organization will decide how to handle your case, with penalties ranging from a professional reprimand to the revocation of your medical license.
Yes, our attorneys have years of experience working with medical providers to build comprehensive compliance programs to minimize the potential for errors during future audits. We can help ensure all staff understand their role in ensuring compliance with the regulations.
