Defending Audits Before They Happen: A Practical Guide to Documenting to Sustain A Challenge to E/M Codes -

Although many believe malpractice suits to be the primary risk-management issue facing healthcare providers, an increasing number of caregivers have learned that the greatest potential risk to the provider's practice is an overpayment audit. This is especially true when there is a risk of terminating a provider agreement of the caregiver's largest payor.

The cases often involve a practitioner who is lulled into the belief that a billing practice was appropriate based on years of payment without contention. Eventually, that provider may open the mail one day to find that the third party payor is suddenly demanding a large refund. The sticker shock of these demands, coupled with the threat of termination of the provider contract, and the likelihood that the caregiver is without coverage for these claims can put a provider at a far greater risk of bankruptcy than even a substantial medical malpractice claim. To make matters worse, in certain cases, providers may face threats of criminal proceedings.