Archive January 2019 XX, No. 1

Legal Update

Medical Billing Audits: The Road to Ruin

Thomas O

Thomas O'Carroll, JD


CLEAN BILL OF HEALTH? Will your billing practices stand up to a federal or commercial payer audit?

It’s a letter you never want to receive, but it’s increasingly likely these days that your facility might get one. It first appears rather innocuous: A federal or private payer asks you for a sample of your billing records — say, 20 to 30 of them. They don’t say why they’re asking, but you comply anyway. That letter almost certainly means that the next letter you receive, sometimes as much as a year later, will be a demand for recoupment of potentially years of billing based on the carrier’s audit of those patients’ records.

In more than 20 years of practice, I have never seen a provider with sufficient coverage lose personal assets in a medical malpractice lawsuit. I have, however, seen medical billing audits not only destroy a surgical business and lead to bankruptcy, but also lead to criminal charges.

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