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Audits questioning the amounts charged by health care providers are on the rise.  Receiving that initial letter can be unnerving, so I’d like to give three pointers.

Identify the auditor.

First, your lawyer should identify who the auditor is.  It could be a commercial insurance company, a Medicare contractor, such as a MAC, a RAC, the SMRC or UPIC, or for more serious audits, a ZPIC, or it could be a Medicaid contractor.  And, once your lawyer has identified who the auditor is, your lawyer needs to make contact.  Your lawyer should establish a relationship with the assigned person, and shouldn’t be afraid to ask for extensions – they are given routinely.

Build a case.

Second, before your lawyer responds, he or she needs to do some homework.  Your lawyer should review relevant medical literature, relevant local coverage determinations, the CPT codebook, and any other relevant manuals.  We once had an auditor claim certain conditions from a local coverage determination weren’t met – when we did some digging, we found out the local coverage determination had been amended, and the amended version didn’t have such conditions.  So, make sure your attorney does his or her homework, and builds a case.  Every plausible challenge to the audit findings should be made.

Negotiate.

Third, don’t be afraid to negotiate.  Understand that the auditors have incentives.  For example, if you’re dealing with a Medicare contractor, it’s likely that the contractor is paid on a contingency fee basis, which means the contractor wants to make some recovery, and then move on.  Use this to your advantage.  Your attorney should have experience dealing with different auditors, and should advise you as to what to expect accordingly.