When it comes to Medicare and Medicaid audits and investigations, nursing homes and hospitals are among the top targets. This is due to various factors, including the vast number of patients enrolled in one or both programs, the vast range of services provided, and the complexity of hospital and nursing home billing systems. Audit contractors are also prone to viewing nursing homes and hospitals as “deep pockets,” where Medicare overpayments are not uncommon.

The knowledgeable and experienced health law attorneys at Norman Spencer & Associates are available to represent hospitals and nursing homes at all stages of investigations, audits and prosecutions. In addition to mounting a strong defense, we can also assist with proactive planning to minimize the chances of being investigated or audited in the first place.

With intense regulation and enforcement surrounding healthcare fraud, audit contractors are greatly incentivized to regain as many overpayments as they possibly can. This applies to audit contractors associated with Medicaid and Medicare, as well as those from private insurance companies.

The result is a notable increase in overpayment audits, many of which target sizable institutions such as nursing homes and hospitals. With a massive scope of services provided to numerous patients under complicated billing systems, auditors are often confident they can find some irregularity that justifies an overpayment determination.

Audits are generally triggered when data analysis programs detect certain irregularities in claims submissions. While the audit may begin by examining those specific irregularities, it can expand in scope based on new information that’s revealed as the process moves forward. Depending on what is uncovered, audit results can lead to deeper investigation or a referral for criminal prosecution.

When an overpayment is suspected, one of the most common allegations is that the provider delivered services that were not medically necessary. The most effective method for countering such an allegation is for providers to present evidence that they adhered to the insurer’s rules and guidelines for determining medical necessity. Overpayment allegations may also arise from improper coding and other errors during claim submission.

Investigations can be initiated by one or more federal and state agencies, and triggered by a variety of suspicions of violations. Suspected violations may involve:

• Fraud or kickbacks
• HIPAA
• Discriminatory hiring practices
• Patient abuse or medical negligence
• Improper dispensing of medications and controlled substances
• Improper disposal of medical waste

The strongest protection against violation accusations is ensuring violations do not occur.

For large and complex institutions like hospitals and nursing homes, monitoring every activity of every employee can be extremely difficult. The answer here is an effective compliance program, one that prevents violations while setting the intent to comply with the law if violations do occur.

Compliance programs must be effective to be worthwhile, and this means they must achieve the desired goals of the institution. The strongest compliance programs will:

• Be tailored to the operations of the specific hospital or nursing home
• Introduce mechanisms designed to prevent, detect and correct violations
• Allow the hospital or nursing home to function properly and deliver exceptional patient care without hampering its ability to do so

The lawyers at Norman Spencer & Associates are extensively experienced in establishing nursing home and hospital compliance programs that take all of the above into account. We ensure the programs align with the facility’s specific needs to best prevent violations while decreasing the risk of investigations and audits being launched in the first place.

Documentation is key when it comes to affecting the outcome of an audit, investigation or prosecution. Based on the goal of the investigation, agencies may request financial, personnel, medical and billing records. Failure to enter and maintain detailed records can not only affect the outcome, but it may be a violation in and of itself. Consulting an attorney provides guidance for recordkeeping best practices.

Staff interviews may also be part of an investigation or audit. Because their statements become an important part of the evidence, it’s imperative your staff members are properly prepared. Advise them not to voluntarily disclose information, even during casual conversations. The best rule is to avoid communication unless your attorney is present.

Hospitals and nursing homes regularly face manifold legal issues that not only impact their daily operations, but can also have significant repercussions on their future. The healthcare lawyers at Norman Spencer & Associates are prepared to help with all legal concerns, from overpayment audits to criminal charges, from representation during investigations to planning compliance protocols.

We understand how hospitals and nursing homes operate, and one of our goals is to ensure the daily workings are disrupted as minimally as possible during ongoing investigations or audits. Another is to navigate the legal and procedural issues to attain the most favorable outcome possible for your particular case.