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Medicare audits can lead to recoupment demands, prepayment reviews, and other administrative penalties. They can also trigger civil or OIG criminal healthcare fraud investigations. Depend on Lowther | Walker for Medicare audit defense attorneys with decades of experience serving medical providers.
Proactively book your free, confidential consultation online or call (404) 496-4052 to discuss our Medicare audit services with our experienced lawyers. Our team can respond in minutes around the clock to protect your practice and preserve your professional reputation.
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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 […]
There are two primary reasons Medicare auditors initiate an audit. The healthcare practitioner is the target of an investigation. Or auditors are working to determine whether an investigation is warranted. The auditing process is never random. Healthcare providers must respond quickly and accurately when the CMS auditors request documentation.
Unlike other forms of Medicare audit, such as Recovery Audit Contractor Audits, ZPIC (Zone Program Integrity Contractor) audits have the potential of criminal charges and severe financial penalties for healthcare practitioners. A request for documentation from ZPIC as part of a ZPIC audit of your billing immediately places your firm and your reputation at risk.
RAC audits help identify and correct improper payments for healthcare services paid to Medicare beneficiaries. RAC audits are either automated, in which case your billing data runs through RAC software to detect compliance issues, or complex, in which an RAC auditor manually reviews patient files in person. A Medicare fraud audit lawyer can help represent you during complex RAC audits to help address potential concerns and prevent potential auditor overreach during the analysis.
In recent years, UPICs (Universal Program Integrity Coordinators) have adopted the role of ZPICs and ZPIC audits. As with ZPIC audits, UPIC audits can lead to criminal penalties for the healthcare provider, and therefore, any communication regarding a UPIC audit should be reviewed with a skilled Medicare audit lawyer.
Because they submit high-dollar claims and high volumes of services, hospitals are frequent targets for audits.
Acute Care Hospitals: Audited for inpatient admissions (IPPS), outpatient services (OPPS), and observation stays.
Long-Term Care Hospitals (LTCHs): Scrutinized for patient admission criteria and length of stay.
Inpatient Rehabilitation Facilities (IRFs): Audited to ensure patients meet the strict criteria for intensive rehabilitation.
Inpatient Psychiatric Facilities (IPFs): Reviewed for medical necessity and appropriate treatment plans.
These organizations frequently face scrutiny over eligibility requirements, duration of care, and documentation standards.
Skilled Nursing Facilities (SNFs): Frequently audited for therapy service levels, resource utilization groups (RUGs/PDPM), and length of stay.
Home Health Agencies (HHAs): Heavily audited to verify that patients are truly “homebound” and require intermittent skilled nursing or therapy.
Hospice Providers: Scrutinized to verify that patients meet the terminal illness prognosis (six months or less to live) and for the levels of care billed (e.g., routine vs. continuous home care).
Size does not exempt a provider from an audit; both large groups and independent doctors are targeted.
Physician Groups and Solo Practitioners: Audited for Evaluation and Management (E/M) upcoding, modifier misuse (such as Modifier 25), and unbundling of services.
Non-Physician Practitioners: Nurse Practitioners (NPs), Physician Assistants (PAs), and clinical social workers are audited for appropriate billing levels and supervision requirements.
Physical, Occupational, and Speech Therapists: Audited for medical necessity, progress documentation, and adherence to therapy caps.
Organizations that provide supportive diagnostic, transport, or medical equipment services are closely monitored for high error rates and historical fraud vulnerabilities.
DMEPOS Suppliers: Providers of Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (e.g., power wheelchairs, CPAP machines, diabetic test strips) face intense scrutiny and are often subject to prepayment reviews.
Independent Diagnostic Testing Facilities (IDTFs) & Clinical Labs: Audited for the medical necessity of high-cost testing, genetic screening, and proper physician orders.
Ambulatory Surgical Centers (ASCs): Reviewed to ensure procedures billed are approved for the ASC setting and coded correctly.
Ambulance Services: Scrutinized to verify that transport by ambulance was medically necessary and that alternative transport was contraindicated.
Pharmacies: Retail and specialty pharmacies billing Medicare Part B (for certain drugs) or Part D.
Audits don’t just happen at the provider level; the insurance plans that administer Medicare benefits are also heavily audited by CMS.
Medicare Advantage Organizations (Part C): Audited primarily through Risk Adjustment Data Validation (RADV) audits to ensure the medical records support the patient diagnoses (HCC codes) used to calculate their risk-adjusted payments.
Prescription Drug Plan Sponsors (Part D): Audited for appropriate formulary administration, rebate tracking, and accurate drug pricing.
All team members, from physicians to the patient intake teams, can be liable for errors made with records and billing details. While Medicare providers operating in high-risk designated locations under the CMS may be more likely to face an audit, Medicare participants across the country face the ongoing risk of an audit at any time.
Understanding the potential penalties after a Medicare audit can give practitioners and their teams context for responding effectively from the initial audit stages. The penalties may include
Recoupment of fees.
CMS auditors can impose recoupment fees on practitioners, for example, requiring the provider to repay Medicare for instances of overbilling and coding errors.
Pre-payment reviews of future claims
Auditors could place pre-payment reviews on a targeted provider’s Medicare claims. Pre-payment reviews involve claims going through a review process before approval, potentially impacting ongoing operating costs.
Denial of pending claims
The provider may have pending claims denied after the audit. While the provider may be able to appeal the denials, the process can delay fee recovery for services rendered.
Exclusion from the Medicare program
The OIG can exclude any Medicare provider convicted of Medicare fraud from the program. The OIG maintains a list of excluded healthcare providers – Excluded Individuals/Entities (LEIE) – and healthcare companies hiring medical professionals on the LEIE are subject to civil monetary penalties.
Under their role of enforcing compliance with Medicare rules and requirements, the Centers for Medicare and Medicaid Services can recommend a referral for a federal healthcare fraud investigation.
Under Title 18, Section 1347 of the United States Criminal Code, healthcare providers can face significant penalties for a medicare fraud conviction. Penalties for a healthcare fraud conviction can include:
Our Medicare audit defense lawyers have proven experience representing doctors, medical equipment suppliers, hospital operators, and other healthcare industry stakeholders during Medicare audits.
We understand the impact Medicare audits have on your healthcare business. The team is available 24/7 to address your questions and concerns. Our ongoing access ensures we can respond quickly when new auditor requests arise.
We have represented healthcare providers and stakeholders at all Medicare audit stages. Our attorneys have experience responding to requests during Medicare audits and helping remove pre-payment reviews and other administrative penalties after audits, representing providers during federal hearings, and defending providers in federal court.
Lowther | Walker has a comprehensive analytical process for defending clients during Medicare audits. Our extensive background in healthcare law and proven experience defending medical providers facing Medicare audits, Medicare fraud investigations, and Medicare fraud charges make our firm the leading choice for proactive Medicare audit defense.
Call upon Lowther | Walker for:
Our first role will be to immediately inform the auditors that all communications will go through our legal team. We ensure that all auditor questions are answered following your legal obligations and remove the burden of audit response from your shoulders, allowing you to focus on your healthcare business.
We tailor our defense strategies to each client’s records and documentation structures. Our initial work involves analyzing the data and determining the scope for risk within the Medicare audit.
Our team watches over the auditor’s working practices to ensure they abide by Medicare billing regulations and calculate payments following the law.
Our comprehensive background as healthcare audit lawyers means our legal team understands the rights of healthcare providers during their audits. We challenge the auditor’s access to documentation and expose any jurisdictional overreach while ensuring they gain authorization to speak with personnel and request records.
Where the auditor identifies an issue during the Medicare audit, our lawyers will precisely respond on your behalf. We harness our knowledge of Medicare laws to demonstrate your adherence to the regulations and resolve concerns before they lead to punitive action.
Take action now to protect your business during Medicare audits. Call Lowther | Walker via (404) 496-4052 to book your confidential, no-obligation Medicare audit consultation or confirm your Medicare audit consultation online.
No-obligation. Fully confidential.
Call Us Today: (404) 496-4052
Your Medicare audit lawyer at Lowther | Walker will require access to relevant financial records, including billing statements and remittances. Our team will also ask for past audit records and your audit notification letter.
Due to the complexity of Medicare regulations, Medicare audits can often lead to inaccurate conclusions surrounding your actions and billing practices. Working with an experienced Medicare audit defense lawyer can mitigate inaccuracies in the auditing process and limit your exposure to potential penalties.
CMS auditors generally target hospitals, providers, and suppliers with high claim error rates or unusual billing practices. Audit targets can also emerge through patient complaints and referrals.
Yes, ZPIC auditors, who have the authority to refer medical providers, equipment suppliers, and hospitals for criminal complaints, can arrive at your facility unannounced. They may then take photos and records to begin the auditing process. Therefore, healthcare teams facing audits and billing inquiries from federal authorities must engage a healthcare audit lawyer as soon as possible.
Inconsistent billing entries, missing pages within practitioner reports, codes not matching documentation, procedures missing documentation, and missing signatures are common red flags in Medicare audits. These elements can trigger further investigations, which may form the basis of civil or criminal charges.
Yes. As Medicare audit lawyers, we can review your entire Medicare compliance structure to mitigate potential legal action against you. Our compliance team can help address weaknesses within your current structures and recommend changes to safeguard you for follow-up audits.
