At best, an insurance audit pulls time and focus away from what matters most—your patients. At worst, it can expose billing inconsistencies that lead to denied claims, clawbacks, or even trigger an investigation into fraud, waste, and abuse.

Many practices make the mistake of responding without a strategy or understanding what private payors are really looking for, raising the risk of costly consequences. When your reputation, revenue, and peace of mind are all on the line, working with experienced healthcare attorneys can make the process clearer, less stressful, and far less risky.

Responding to insurance audit requests

Private insurance audits typically begin with a letter requesting a sampling of patient medical records. Once they review the first batch of documents, insurers may ask the practice to supplement them with additional records, or escalate the audit if they find red flags.

We guide healthcare practices through the audit process by:

• Reviewing the audit letter and working collaboratively to respond
• Navigating HIPAA issues involved with the requested records, ensuring that information subject to heightened privacy standards is handled appropriately
• Addressing any missing, incomplete, or inaccurate records in a proactive way that complies with the insurance company’s standards and satisfies legal and ethical obligations to maintain full and complete patient records

Once the initial batch of records has been delivered to the insurance company, it is common for them to send supplemental requests. The healthcare attorneys of Jackson LLP can work with the insurer to navigate deadlines, address inconsistent or duplicative requests, and ensure that the scope of the request is congruent with the insurer’s audit authority.

Proactively auditing practice records

One of the best ways to prepare for an insurance audit is to conduct one! We perform independent audits for practices to evaluate:

• Practitioner compliance with recordkeeping requirements
• Practitioner and practice compliance with billing codes
• Compliance with individual insurance company and practice policies, including prior authorization requests or appeals
• Possible risks or violations of healthcare fraud, waste, and abuse laws

By performing a proactive audit, our attorneys will consider a randomly selected set of records representing all of a practice’s providers, locations, and insurers. We’ll then undertake a comprehensive evaluation of those records. We will provide detailed feedback to the practice, including recommendations for improving compliance with insurance billing requirements, the Anti-kickback Statute, Stark Law, and more.

Strategic support for private payor audits

If you’re dealing with a records request from an insurer, we can help you respond efficiently and reduce the risk of overpayment demands or clawbacks. Our healthcare attorneys know how private payors operate and how to push back when their audit tactics exceed contractual or legal limits.

If you’re facing a Medicare or Medicaid audit, we also offer support for government audits.