Tell us about your practice
I advise hospitals and health systems, ambulatory surgery centers, clinical laboratories, physician and physician practices, hospice, and durable medical equipment suppliers on regulatory compliance and fraud and abuse matters. I also routinely conduct internal investigations of regulatory, compliance and clinical concerns and represent clients in responding to governmental inquiries and related litigation concerning alleged violations of various healthcare laws and regulations, including the False Claims Act. I specialize in representing clients in payor claims audits, including those performed by Recovery Audit Contractors (RACs), Program Safeguard Contractors (PSCs) n/k/a Zone Program Integrity Contractors (ZPICs) and Medicaid Integrity Contractors (MICs), and if needed, in addressing adverse results from these audits through administrative proceedings and litigation.
What trends are you seeing relating to Zone Program Integrity Contractors (ZPICs) and other Medicare and Medicaid audit contractors, and what is your prediction for the future of payor claims audits?
The audits are increasingly relying on data analysis conducted by the contractors to identify trends and outliers in the data. These audits also are more frequently leading to other enforcement actions, such as payment suspensions and exclusions from the Medicare and Medicaid programs. I predict that the number of audits by the Medicare and Medicaid audit contractors will continue to increase, and the contractors will develop even more sophisticated data analysis tools to target providers. Healthcare providers should be proactively analyzing their data to identify any potential billing issues and take corrective action before becoming an audit target. When appealing audit results, healthcare providers should prepare for the appeals process to take many months to several years. The entities handling the administrative appeals have admitted that they are overwhelmed with the number of appeals and cannot process them in the time frames that were originally intended for these appeals to be completed. Healthcare providers should develop a strategy for addressing claims appeals in light of the extended delay in reaching a resolution.
What is the most fulfilling part of your job?
Helping my clients to take advantage of the opportunities in the ever-changing healthcare industry and accomplish their business objectives while remaining compliant with the regulatory framework in which they have to operate.