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Being Unprepared for Medicare Audits Can Cost a Medical Practice Millions of Dollars

Dennis Alessi , Chair of our Health Care Law Practice, was asked to represent a cardiology practice after its billing to Medicare had been audited. Though only 31 patient charts were audited, Medicare extrapolated from these few charts that it was entitled to recoup over $1 million of payments to the practice in just one year. It claimed that the practice’s clinical notes did not adequately support the need for the services it billed to Medicare.

With the assistance of billing and cardiology experts, Dennis was able to establish that all the patient charts included sufficient physician notes to support the medical necessity of the services provided, and the charges to Medicare. However, Medicare has certain additional coverage requirements that must be present when the patient is examined, and must be documented in the chart, before it will approve payment for a particular service the physician provided.

Unfortunately for our client, many of its patient charts did not address these additional coverage requirements, and there was no means by which this defect could be remedied after the audit had been completed, and our firm was retained. Consequently, Dennis was able to affect only a partial reduction of the payments Medicare sought to recoup.

As this cardiology practice will definitely be a target for further Medicare audits, Dennis is implementing a clinical recordkeeping and billing compliance plan to ensure that future audits will not result in further financial losses for our client.

This case is a lesson to all health care providers that they must have such compliance plans in operation to avoid Medicare audits that can result in significant monetary losses.


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