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Medical Providers Can Face License Sanctions From Insurance Audits

Posted on February 16, 2023 in Medical License Defense

IL license defense lawyerFew things can arrive in the mail that physicians and other healthcare providers dread more than a letter announcing an insurance audit. Whether this is from a private health insurance company or Medicaid/Medicare, audits mean a lot of paperwork, deadlines, and other bureaucratic complexities are in the future. Even a physician who believes herself to be in full compliance with proper billing procedures may be surprised to find that mistakes have been made - and if there are enough mistakes, that there could be serious professional consequences. Having the help of an Illinois professional license defense attorney can make all the difference in the outcome of an audit case, so do not wait to secure legal representation if you are going to be audited.

Be Prepared - Tips For Protecting Yourself in an Audit

Because of the significant risk of being audited, and the potentially harsh consequences associated with inconsistent or fraudulent insurance records, the Physicians Advocacy Institute has recommendations for doctors and other medical practitioners to protect themselves in an audit. These include:

  • Assessing your practice’s risk of being subjected to an audit before you are ever notified of one
  • Evaluating your practice’s compliance with billing procedures
  • Ensure that either yourself or a designated team member are equipped to respond appropriately to requests for documentation
  • If you are audited, determine the type of audit right away (commercial insurance, Medicare insurance, etc.)
  • Conduct your own assessment of the practices or records being audited
  • Comport yourself professionally by meeting deadlines, being cooperative, and asking for extensions well ahead of time
  • Be prepared to file an appeal if you disagree with the audit’s results

Audits are most often conducted on physicians or practices that appear to be deviating from the habits of their peers in the same field; this could be due to deliberate fraud or mistaken billing errors, among other reasons. Whatever the reason, you risk facing professional penalties if you are found to be out of compliance.

In addition to the risk of a “clawback,” or having to pay back the insurer for payments found to be in error, practitioners who fail audits face disciplinary actions from the private health insurance company, the Centers for Medicare & Medicaid Services (CMS), and the Illinois Department of Financial and Professional Regulation (IDFPR). This includes having to take additional measures to ensure future compliance with correct procedures, financial penalties, the loss of Medicare and Medicaid billing privileges, loss of hospital privileges, and even professional license sanctions.

Contact an Illinois Professional License Defense Attorney

If you have been notified of an insurance audit, waiting to find out the results before hiring an attorney could leave you vulnerable. Get help right away from an experienced Illinois professional license defense attorney who can provide legal guidance throughout the audit and help you defend against possible threats to your practice. Call The Law Offices of Joseph J. Bogdan, Inc. today at 630-310-1267 to schedule a free consultation and learn more.



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