At best, an insurance audit is a time-consuming distraction from your practice’s core mission of patient care. At worst, an audit can reveal inconsistencies that result in unpaid claims or even an investigation of fraud, waste, and abuse. With so much at stake, the guidance of experienced healthcare attorneys can help lessen the stress and the peril of an audit.

Responding to insurance audit requests

Practices often audit their records only when required by a third-party payor or the government. Insurance company and CMS audit letters typically request a sampling of the practice’s patient medical records. Once they review the first batch of requested documents, they may ask the practice to supplement them with additional records.

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 or CMS’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.

Guidance from experienced insurance audit attorneys

Contact us for assistance with:

• UPIC/ZPIC audit
• Medicare / CMS audit
• Private insurer audit

We also handle HIPAA audits.

To prepare for or respond to an audit, reach out to one of our attorneys. Schedule a free consultation to learn if Jackson LLP is a good fit for your insurance audit needs.