Very often a healthcare provider – when confronted during the audit on a recordkeeping deficiency or some other practice – starts arguing with the auditor: this is how it’s always been done, everybody is doing this, I know better what is right for my patients, etc. Not the best tactic when you are facing a substantial recoupment or your contract is at stake. Instead, tell a story: collect your evidence – including legal arguments and precedents – showing that your practice complies with the standard of care and that you have complied with the law and contractual terms. For example, recently Medicaid and Medicare have been recouping (and causing other problems) based on cut-and-paste notes arguing that every service should be individualized and pasting the notes from one patient to another puts legitimacy of the service at doubt. If that’s the case, do not argue but tell your story: include other individualized records for that specific patient to show that this was a legitimate service provided. The auditor is looking at plain numbers and dry text – turn your records into a story. Also, even if not too much money is involved in the audit, do your appeal anyway. Failure to do so, may result in subsequent increased audits.
I can’t tell how many times we could have helped our client in a more efficient way, if we were engaged earlier on. Even if the question is a technical one, contact your counsel who can protect your legal interest, which can come handy at a later stage. For example, if you are dealing with a Medicare reimbursement appeal (or Medicaid), the counsel can help you navigate the appeal process and make sure the agency or its contractor is complying with the appeal rules, correctly interprets contractual language and applicable rules and regulations (you’ll be surprised how often a government auditing agent neglects these). Also, the counsel can help you with procedural details. For example, with Medicare you have 120 days to appeal, but you should do it in 30 days to prevent recoupments and start the appeal process. Medicare and Medicaid hearings are conducted in a different manner. For example, a Medicare hearing takes forever to schedule – currently over 3 years and it is done via the phone. While Medicaid is an in-person hearing and you can negotiate. When lots of money is involved in the audit, we engage experts to which the agency will listen and who have no interest in the outcome. In other words, your counsel is your asset during an appeal process and not an expense.
Don’t confront but tell stories (with your counsel by your side).