CHICAGO – The first rule of a billing audit, according to Dr. Brent Moody: "Don’t take it personally."
Audits are about money, and "there’s always going to be a winner and a loser," he said at the American Academy of Dermatology summer meeting.
Dr. Brent Moody
To raise the odds of winding up on the winning side of an audit or billing investigation, Dr. Moody advised taking the following steps.
Consider retaining legal counsel. The need for an attorney depends on the size, scope, and seriousness of the audit.
"You may be able to handle it on your own" if a small number of records are requested, he said. But a Recovery Audit Contractor (RAC) audit request for dozens or hundreds of chart records could indicate a more serious audit investigation. "If they come back to you with a big recoupment or a really broad request, you may want to think about getting legal help."
Legal counsel is strongly recommended if audit investigations evolve into allegations of False Claims Act (FCA) violations or qui tam lawsuits, said Dr. Moody, a Nashville dermatologist and the chair of the public policy committee for the American College of Mohs Surgery. The federal FCA law sets criminal and civil penalties for falsely billing the government, overrepresenting the amount of a delivered product, or understating an obligation to the government. Qui tam lawsuits are civil claims under the FCA in which whistle-blowers are rewarded if the claims uncover fraud and recover funds for the government. Both types of cases can mean the involvement of federal authorities, seized documents or equipment, and potential criminal charges.
FCA violations or qui tam lawsuits "are serious issues. You need legal help, and you need it right away," he said.
Decide whether to fight or pay. Complying with a recoupment will reduce hassle and more quickly resolve an audit. An appeal makes sense if the request is erroneous or unfair. Appealing within 30 days halts the recoupment but does not stop interest from accruing.
A letter of rebuttal – a formal statement as to why the recoupment should not take place – is ideal when the wrong doctor or practice has been audited or the audit violates state rules on look-back timelines. Health providers have 15 days to rebut upon notice of an impending recoupment action. Another option is to negotiate by paying the recoupment sum, but getting the auditors to agree that no further look-backs will occur from a certain time frame.
Do your audit homework. Audit resources and information are available from the American Medical Association and state medical societies. The American Academy of Dermatology provides a RAC audit toolkit, and many other medical organizations can provide answers to common audit questions and attorney referral lists.
Be civil to your auditor. While challenging, remaining cordial and respectful to auditors during the audit process can ultimately work in the physician’s favor. "At the end of the day, they are just people doing a job," Dr. Moody said. "Talk to them and try to figure out exactly what they are looking for. You don’t want to fight the wrong battle."
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