Medicaid, Medicare, insurance networks and other health benefit programs and payors are increasingly utilizing audits to detect fraud and monitor utilization and coding compliance. Health professionals, including physicians, dentists, podiatrists, chiropractors, mental health professionals and physical therapists and entities, such as pharmacies, medical and surgical suppliers and ambulette / transportation services are subject to audits. Audits can result in demands for substantial amounts of repayment, pre-payment reviews of claims, withholding of payments and termination of provider enrollment. The outcome can result in reports of sanctions to the National Practitioner Data Bank and referrals to the Office of Professional Discipline (OPD), Office of Professional Medical Conduct (OPMC) and for criminal investigation.

Our firm is experienced in representing clients in all aspects of audits including:

  • Initial audit notices, including subpoenas, letter requests for records and notices of withholding of payments and pre-payment claims reviews.
  • Review and assessment of records and engagement of consultants to determine potential issues.
  • Review of audit findings and preparation of responses on the merits and statistical / sampling issues.
  • Negotiation of audit settlements to minimize clients’ financial exposure, termination of enrollment and referrals to Medicaid, Medicare and OPD/OPMC.
  • Post audit representation in administrative hearings and civil litigation.

Experienced representation from the outset of an audit can minimize financial exposure and the impact upon other professional privileges. Please contact Amy Kulb at 516-222-2330 or [email protected] for further information, consultation or representation in audits.