It is not at all unusual for health care providers to discover potential billing and overpayment issues in the course of their day-to-day operations. Such issues may arise in any number of ways. For instance, they may be identified as the result of a provider’s internal compliance efforts, including compliance program audits or reviews, or as a result of internal investigations into errors found by billing or other personnel. They may also be identified as a result of external factors, such as payer audit findings that raise billing and payment questions that extend beyond the time period covered by the audit, or by external complaints.
Regardless of how an issue arises, however, it is important that providers timely investigate the matter and take appropriate corrective action. Often, however, providers are unaware of what they must do to – and when they must do it – in order to avoid legal peril. For example, providers who identify federal health care program overpayments are required to report, return and explain the overpayments within 60 days from the date they are identified. The failure to do so can have severe consequences, including potential liability under the federal and/or state False Claims Acts. Timely refund obligations also commonly exist elsewhere in the law, including in contractual network agreements between a provider and a payer. It is essential that providers to be mindful of, and abide by, these obligations. Even if providers are aware of the need to act, they often do not know how to proceed or do not have the expertise needed to do so.
These matters often pose complex and difficult factual, coding and legal issues: Payment policies and rules may vary from payer to payer, may change over time and are often unclear; myriad legal issues may exist depending on the payers and providers involved. When an issue is first identified, it is often important to have billing and documentation experts review the matter in conjunction with legal counsel in order to ensure that the correct payer rules and laws are being followed, and that the matter is timely and appropriately addressed. Consulting with a documentation and coding expert, such as Garfunkel Health Advisors, and legal counsel early in the process may help ensure that the issue is appropriately handled and that a provider’s exposure is appropriately mitigated, to the greatest extent possible.
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