Healthcare Billing, Reimbursement, Audits, and Appeals

What does a Medicare audit attorney do for healthcare providers?

Medicare, Medicaid and commercial payers audit healthcare providers constantly, and an audit can turn into a demand to repay money that was billed and collected years ago. A Medicare audit attorney, sometimes called a healthcare audit lawyer, helps a provider respond to the audit, challenge the findings, protect revenue during the appeal, and fix the billing practices that drew the attention in the first place.

Jimerson Birr’s healthcare team works with hospitals, clinics, laboratories, surgical centers, physician groups, long-term care facilities and durable medical equipment providers on Medicare and Medicaid audits, overpayment disputes, reimbursement appeals and payer contract disputes.

Which audits do Florida healthcare providers face?

Most audits start with a records request. Who sent it tells you a great deal about what is at stake.

• Recovery Audit Contractor (RAC) audits. RACs review paid Medicare claims for improper payments and are paid on what they recover. A RAC audit generally reaches back three years from the claim payment date.
• Unified Program Integrity Contractor (UPIC) audits. UPICs replaced the older ZPICs and Program Safeguard Contractors. A UPIC audit focuses on potential fraud, waste and abuse in Medicare and Medicaid, and can lead to payment suspension, extrapolated overpayments or referral to law enforcement. A UPIC or ZPIC audit deserves an immediate legal response.
• Targeted Probe and Educate (TPE) reviews. A Medicare Administrative Contractor reviews a sample of your claims, typically 20 to 40, and offers education after each round. Providers who do not improve after up to three rounds can be referred for 100 percent prepayment review, extrapolation or a RAC audit.
• Florida Medicaid audits. The Agency for Health Care Administration’s Bureau of Medicaid Program Integrity audits Medicaid providers and pursues overpayments and sanctions under section 409.913, Florida Statutes. A Medicaid audit attorney can challenge those findings through Florida’s administrative hearing process.
• Commercial payer audits. Private insurers and managed care plans audit claims under the terms of their provider agreements and often recoup by offsetting future payments.

How do Medicare overpayment appeals work?

Original Medicare has five levels of appeal, and each has its own deadline. A Medicare appeals attorney makes sure every deadline is met and every argument is preserved for the next level.

1. Redetermination by the Medicare Administrative Contractor, requested within 120 days of the initial determination.
2. Reconsideration by a Qualified Independent Contractor, requested within 180 days of the redetermination decision.
3. Hearing before an Administrative Law Judge, requested within 60 days, where the amount in controversy meets the annual threshold.
4. Review by the Medicare Appeals Council, requested within 60 days.
5. Judicial review in federal district court, filed within 60 days, where the amount in controversy meets the higher annual threshold.

Timing matters for cash flow as well as rights. When a provider files a redetermination request within 30 days of the overpayment demand letter, Medicare generally cannot recoup the overpayment while the first two levels of appeal are pending, as long as each appeal is filed promptly. Miss that window and Medicare can start offsetting your current payments while you appeal.

Can an extrapolated overpayment be challenged?

Yes. Auditors often review a small sample of claims, find errors, and project the error rate across hundreds or thousands of claims. A modest sample can become a seven-figure demand. Extrapolation must follow statistical sampling rules, and flaws in how the sample was drawn, how the universe was defined or how errors were counted can reduce or eliminate the projected overpayment. Challenging the sample is often the most valuable work a Medicare audit attorney does in a large audit appeal.

How should a provider respond to an audit records request?

• Calendar the response deadline the day the request arrives. Late or incomplete records are a common reason claims are denied.
• Produce complete records for each claim, including orders, signatures, medical necessity documentation and proof of delivery where required.
• Have a Medicare audit attorney review the submission before it goes out, particularly for a UPIC audit or any request that suggests fraud concerns.
• Look at what the audit is targeting and correct the underlying billing or documentation practice now, before the next review.

When does a billing problem become a False Claims Act problem?

Most billing errors are just errors. But a provider that learns it has been overpaid generally has 60 days to report and return the overpayment, and knowingly keeping it can create liability under the federal False Claims Act. If an audit, internal review or employee complaint suggests a pattern rather than a mistake, see our False Claims Act litigation page for how that exposure is handled.

Frequently Asked Questions

Do I need a Medicare audit attorney for a records request?

Not for every request, but counsel is worth involving early for a UPIC audit, any request tied to a large number of claims, or any audit after a prior denial. The records you submit at the start often decide the appeal.

Can Medicare take money back while I appeal?

It can unless you act quickly. Filing a redetermination request within 30 days of the demand letter generally stops recoupment during the first two levels of appeal.

Does Florida Medicaid follow the same appeal process as Medicare?

No. Florida Medicaid overpayment determinations are made by the Agency for Health Care Administration and are challenged through Florida’s administrative process, which has its own deadlines.

Facing a healthcare audit or overpayment demand?

Audit deadlines are short and the first response shapes the outcome. Contact Jimerson Birr or call (904) 389-0050 to speak with a Medicare audit attorney about your audit, overpayment demand or reimbursement dispute.