Health care providers that service the Medicare and Medicaid population are expected to know and comply with a complex and constantly evolving program. In today’s regulatory landscape – which closely scrutinizes waste, fraud, and abuse – errors in claims and billing practices can lead to audits and recoupment of overpayments. Violations of health care laws identified in these audits can also result in fraud investigations and substantial penalties, including hefty fines, exclusions from Medicaid and Medicare, the loss of a professional license, and even criminal prosecution. With stakes as high as these, ensuring compliance and deftly handling audits and investigations becomes a top priority.
As one of the pre-eminent health care law firms in Texas, Hendershot, Cannon, Martin & Hisey draws from decades of experience to provide health care businesses and facilities with preventative legal counsel and defense against recoupment, lawsuits, fraud investigations, and penalties. Our services center on a comprehensive approach to billing practices and effective measures to mitigate exposure to penalties resulting from errors and violations.
Learn more about our health care law services. Call (713) 909-7323 for an initial consultation.
As defined by the Centers for Medicare & Medicaid Services (CMS), a Medicare or Medicaid overpayment occurs when a health care provider receives payment that exceeds amounts properly payable under statutory law and regulations. When an overpayment is identified, it becomes a debt owed to the federal government that must be recovered. The underlying cause must also be identified, including:
Our firm represents providers during all phases of audits, including those conducted by MACs and RACs for overpayments, and ZPICs, which specialize in investigating fraud. This includes guidance through matters involving demands for recoupment, which persist even when fraud investigations are initiated, and the recoupment appeals process, which consists of:
Preventative practices and pro-active handling of Medicare and Medicaid overpayments are essential to avoiding audits, the overpayment recovery process, and recoupment.
Avoiding audits and recoupment begins with proactively ensuring clear and executable billing practices, airtight documentation, and compliance that can be clearly demonstrated. Because “an ounce of prevention is worth a pound of cure,” especially when it comes to Medicaid and Medicare claims, health care providers can work with our experienced attorneys to review medical documents, agreements, billing practices, and other essential components of their practice to ensure they are operating in compliance with applicable laws and not at risk of violating rules.
In addition to avoiding recoupment, preventative legal counsel is also essential toreducing risks of fraud investigations that can result from improper practices identified during audits and referred to enforcement agencies, or from violations identified through other means, including whistleblower lawsuits.
Given the complexities of Medicaid and Medicare, it is often the case that providers don’t knowingly violate the law. However, when violations occur, subsequent fraud investigations can create tremendous challenges, as well as exposure to penalties that threaten a practice and one’s professional livelihood. In addition to proactive counsel and guidance through audits, overpayment issues, and the recoupment appeals process, our firm also provides defense against fraud investigations.
Our defense services focus on representing providers that have been notified of investigations through letters received by various entities – including the Office of Inspector General (OIG), Texas Department of Insurance (TDI), or Attorney General’s Office – or upon issuance of a warrant, subpoena, or unexpected shut down of a practice. Such investigations can be triggered by a number of things, including:
Whether an investigation stems from a qui tam lawsuit, an audit conducted by TDI or a CMS contractor, or other issues of inconsistencies and unusual patterns that may constitute Medicaid and Medicare Fraud, taking decisive action to consult an attorney immediately is critical to an effective defense. An early defense and representation during investigations and interviews is also critical to avoiding what can be severe and life-altering consequences, such as:
From establishing sound practices and compliance to handling overpayment audits, requests for recoupment, appeals, and investigations over fraud, waste, and abuse, our legal team at Hendershot, Cannon, Martin & Hisey is equipped with the experience, insight, and resources to effectively provide all medical practices with the comprehensive counsel and tailored representation they need.
If you have questions regarding health care provider billing practices as they relate to Medicaid or Medicare, or wish to discuss a potential audit or fraud investigation, do not hesitate to speak with a member of our team about your rights, options, and the journey ahead. Contact us for an initial consultation. Our Houston-based lawyers serve clients throughout the state of Texas.