Medicare, Medicaid & Audits

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Collora LLP helps clients prepare for and respond to audits conducted by carriers or administrators for Medicare, Medicaid or private insurance programs.

The regulations governing Medicare and Medicaid providers are exhaustive and complex. We help our clients with program audits through the local Medicare carrier, the Office of Inspector General, or the Division of Medical Assistance among others.

Requested records are subject to rigorous review, and both Medicare and Medicaid steadfastly adhere to a policy that enforces failure to follow rules and regulations to the very letter, including rules about complete documentation.  Medicare and Medicaid shall deem such failure as grounds to deny all reimbursement for any audited service. Our attorneys are particularly effective in resolving audit problems, often limiting the audit exposure of providers, defending their billing practices, proposing plans of correction as alternatives to debarment or other sanctions and, when necessary, persuading an auditing agency that mistakes do not warrant referral of a matter to law enforcement.

Collora represents many clients in health care audit matters, including:

  • Carriers or Third Party Administrators for Private Insurance Programs

  • Clinics and Specialty Care Centers

  • Hospitals and Nursing Homes

  • Medicare and Medicaid Providers

  • Physicians and Practice Groups of Physicians

  • Providers Dealing with Carriers or Third Party Administrators in Private Insurance Programs

Our lawyers successfully deal with many different issues associated with health care billing audits, including:

  • Alleged Provision of Medically Unnecessary Services

  • Alleged Overbilling, Upcoding and Retention of Overpayments

  • Improper Application of Extrapolation Theory to Small Percentages of Claims

  • Persuading Agencies that Mistakes are not Appropriate for Law Enforcement Referrals

  • Potential Fraud and Abuse Claims Arising Out of Audits

Representative Experience

  • Successfully reduced the amount of alleged overpayments sought by agency for Medicaid administration, obtaining a fifty percent reduction of amount sought in initial notice of overpayments to physician. Also persuaded agency to reverse an initial decision to suspend the doctor from participating in the program.

  • Represented holistic medical provider in initial audit by NHIC (the Medicare carrier), and in appeal to NHIC and in further appeal to U.S. District Court. Obtained ruling from U.S. District Court that reversed NHIC decision, validating the provider’s practice and the tens of thousands of claims he made for reimbursements.

  • Successfully defended billing and coding practices in question and/or persuaded the pertinent auditing agencies that billing errors were not grounds for debarment or other harsh sanctions.

  • Represented third party carriers, as well as medical providers in many contests concerning billing and coding disputes, obtaining successful settlements, defending billing practices, or recapturing substantial portions of billings.