If you are a healthcare provider, you are bound to get audited at some point. Who conducts that audit (this includes federal authorities such as the Department of Health and Human Services (HHS), the Center for Medicare and Medicaid Services (CMS) and Unified Program Integrity Contractors (UPICs) or private health insurance audits) and what has triggered it should influence how you defend against it. However, certain defense strategies broadly apply to both government and private healthcare audits.
Dr. Nick Oberheiden is a healthcare audit defense lawyer at the national law firm Oberheiden P.C. He has helped numerous health care providers, professionals, and pharmacies prepare for and pass public and private healthcare audits, and has protected the interests of many other healthcare providers by mitigating the damage of a failed audit. Here are four defense strategies that he often uses for healthcare providers who are being audited.
1. Get Details About the Scope of the Audit
If possible, you should get as many details about the upcoming audit process as you can. This can help you prepare for it and can give you a sense of what the auditing party is looking for.
In many cases, whatever notification that you receive about an audit will be vague. Auditors often try to hide their intentions or the reason for the audit because they think that being open with these details will enable the target of the inspection to hide information or evidence of wrongdoing. They generally only provide nebulous descriptions of the types of information that you will be expected to provide and the areas that are to be open to the auditor to inspect.
Sometimes, reading between the lines of these vague instructions can be enough to give you a good idea of what is going on. For example, if all of the information requests have to do with billing codes, then the audit is likely going to look for evidence of healthcare fraud and overbilling.
Most of the time, though, the notification does not provide enough clues. In these cases, it can be wise to reach out to the auditing agency and request more information. This can help you learn more about what to expect, as well as help you gather the documents and information that they are going to want to see. Not only will you go into the audit process with open eyes, but you will also save some time by having more concrete details about what to provide.
Unfortunately, in some cases, this is not possible. If the auditor shows up unannounced at your door, any information they can provide about the audit will not make it any less surprising or stressful.
2. Monitor the Auditor
While the audit is ongoing, it is crucially important to keep an eye on the auditor. You need to ensure that he or she only inspects the areas and the documents such as patient records or billing records and other information that were outlined in the scope of the audit. Confining the auditor to the scope of the inspection can avoid a potentially devastating situation where he or she finds incriminating evidence that they should not have had access to.
Of course, controlling the auditor should be done carefully. If you are too strong or too confining and cannot justify the limitations, you can get accused of interfering in the inspection.
One way to do this appropriately is to control which personnel the auditor has access to. The scope of the audit should include enough details for you to understand who the auditor needs to speak with. Keeping the auditor from interacting with others at your business can avoid a situation where multiple people provide different answers to the same question. This can lead to the auditor having to investigate the discrepancy, which can prolong the process. Insulating others at your business from the auditor can also free them from the hassle of the inspection and keep your business running as smoothly as possible while the audit is ongoing.
3. Have an Audit Playbook Ready to Go
Mistakes are made and audits are failed when the investigation creates chaos in your business. If you are not ready, you can disclose incriminating information without meaning to. Also, the sense of unpreparedness raises the suspicion of seasoned auditors, who see any disorganization at your company as a sign that they are likely going to find the discrepancies that they are looking for.
Having a playbook for audits on hand and ready to implement at a moment’s notice is crucial for healthcare providers. All of your personnel should have a role to play in the audit, even if it is as small as redirecting the auditor’s questions to their supervisor. The playbook should also create a small team whose only job during the audit is to respond to it. This team should be composed of executives and other personnel who are knowledgeable about the topic being audited.
4. The Best Audit Defense Strategy is a Strict Compliance Strategy
Overall, though, the best defense strategy for a healthcare audit is to have an all-encompassing and stringent compliance strategy in place. By crafting an effective one and then sticking to it, the odds that you pass an audit increase substantially. Given how audits are rarely routine, anymore, and are instead triggered by data analysis that has uncovered signs of misconduct or billing discrepancies, having a good compliance strategy in place and doing a regular internal audit can also reduce the chances that your company is ever audited, in the first place.
As Dr. Nick Oberheiden, a healthcare audit defense lawyer at the national law firm Oberheiden P.C., says, “Healthcare audits are an example of the old saying, ‘an ounce of prevention is worth a pound of cure.’ Healthcare companies that adhere closely to an effective compliance strategy every single day are far more likely to avoid liability after an audit than those that do not take compliance seriously. In that sense, the vast majority of your defense against an audit happens well before one is performed. While there are still several steps that you can take during the audit to protect your interests, it is the compliance stage that will matter the most in the long run.”
