Defense of Complex Audits

A post-payment audit is the payor's opportunity to claw back claims it has already paid. The firm's signature capability is the in-house auditing function: certified coders and former auditors who reconstruct the medical record and the claim from the same vantage point the auditor used to challenge it.

Audit response and statistical sampling defense

We respond to record requests on a timeline that protects the provider, audit the auditor's statistical sampling methodology, and challenge extrapolations that do not withstand the math.

Rebuttal and reconsideration

We prepare rebuttals to the audit findings using the medical record, the coding guidelines in effect on the date of service, and the regulatory framework that governs the specific service line.

ALJ and federal review

For Medicare audits, we represent providers through the five-level appeal process, redetermination, reconsideration, ALJ hearing, Medicare Appeals Council, and federal district court.

Voluntary self-audit

A voluntary self-audit is a review a provider initiates on its own, before any payor or agency has asked for records. The firm conducts the review under attorney-client privilege, examining a defined sample of claims against the coding guidelines and coverage rules in effect on each date of service.

The scope is agreed in advance: which payors, which service lines, which date range, and how many claims. We report what the review found and explain the options available under the applicable self-disclosure protocols, including the circumstances in which a provider may choose to make a voluntary disclosure or repayment. The decision whether to disclose is the provider's to make, and we advise on it rather than make it.

What a self-audit cannot do is tell you in advance how a payor or agency will respond. We do not predict outcomes, and no description on this page should be read as a promise about how any particular review will be received. Every engagement is assessed on its own facts.