Medicare/Medicaid/TPA Audits
Collora LLP has helped numerous clients to prepare for or respond to audits conducted by carriers or administrators for Medicare, Medicaid or private insurance programs.
The regulations governing Medicare and Medicaid providers in particular are exhaustive and complex. That is why few providers survive a program audit - whether by the local Medicare carrier, the Office of Inspector General, or the Division of Medical Assistance - without a government claim for some reimbursement of overpayments.
Requested records are subjected to rigorous review, and both Medicare and Medicaid steadfastly adhere to a policy that failure to follow rules and regulations to the very letter, including rules about complete documentation, are grounds to deny all reimbursement for any audited service. Both programs also use an extrapolation theory to project a total overpayment amount based on billing mistakes allegedly found in the audit of a small percentage of claims.
Our attorneys have been particularly effective in this area, limiting the audit exposure of providers, defending their billing practices, proposing plans of correction as alternatives to debarment or other sanctions, and when necessary persuading an auditing agency that mistakes do not warrant referral of a matter to law enforcement.
We are pleased to share with you the following executive summary showing the kinds of clients we have represented in health care audits, the legal issues we have handled for them, the forums in which we have appeared, and some of the representative results that we have produced for them. (For information about our other health care advocacy services, see links at the bottom of this page.)
Clients
Collora LLP has represented many clients in health care audit matters, including but not limited to:
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Physicians and Practice Groups of Physicians
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Hospitals and Nursing Homes
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Clinics and Specialty Care Centers
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Other Medicare and Medicaid Providers
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Providers Dealing with Carriers or Third Party Administrators in Private Insurance Programs
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Carriers or Third Party Administrators for Private Insurance Programs
Issues
We have successfully dealt with many different issues associated with health care billing audits, including but not limited to the following:
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Alleged upcoding
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Alleged retention of overpayments
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Alleged provision of medically unnecessary services
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Alleged overbilling
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Improper Application of Extrapolation Theory to Small Percentages of Claims
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Potential Fraud and Abuse Claims Arising Out of Audits
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Persuading Agencies that Mistakes Are Not Appropriate for Law Enforcement Referrals
Forums
Our lawyers have appeared in many forums for resolution of billing claims related to health care audits. We can provide you with lawyers who not only understand the relevant legal issues, but are familiar with the rules, procedures and operations of the relevant forums for judgment and appeal, including:
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Forums for hearings and appeals hosted or utilized by the Centers for Medicare and Medicaid Services or its contractors, such as NHIC Corp., the Medicare administrative contractor for New England
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Forums for hearings and appeals hosted or utilized by the Office of Inspector General, the Division of Medical Assistance or its contractors (for Medicaid)
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Hearing panels and appeals boards hosted by or utilized by Blue Cross and Blue Shield, Harvard Pilgrim, and other private carriers or third party administrators
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Massachusetts Superior Court
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Massachusetts Appeals Court
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Supreme Judicial Court
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U.S. District Courts
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U.S. Circuit Courts of Appeal
Results
The following summaries are a representative sampling of results we have produced for our clients in matters related to health care billing audits.
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Successfully reduced the amount of alleged overpayments sought by agency for Medicaid administration, obtaining a 50 percent reduction of amount sought in initial notice of overpayments to physician. Also persuaded agency to reverse an initial decision to suspend the doctor from participating in the program.
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Successfully represented holistic medical provider in initial audit by NHIC (the Medicare carrier) and in appeal to NHIC and in further appeal to U.S. District Court. Obtained ruling from U.S. District Court that reversed NHIC decision, validating the provider’s practice and the tens of thousands of claims he made for reimbursements.
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Successfully defended billing and coding practices in question and/or persuaded the pertinent auditing agencies that billing errors were not grounds for debarment or other harsh sanctions.
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Represented third party carriers, as well as medical providers in many contests concerning billing and coding disputes, obtaining successful settlements, defending billing practices, or recapturing substantial portions of billings.
For more information about other forms of civil advocacy we provide to clients in the health care sector, click on any of the pertinent links below.
For information about our legal representation of health care clients faced with actual or potential government enforcement actions, click on the link below.