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The Healthcare Services Group has been actively involved in healthcare litigation work. Our certified coders have worked directly with healthcare attorneys in the following key areas:

Fraud and Abuse

Over the past two years there has been a significant increase in fraud and abuse audits requested by both governmental and commercial payors as well as the Office of Inspector General (OIG).

The most common reason for the audits has been for coding a disproportionately high volume of high-level Evaluation and Management (E&M) codes that result in increased reimbursement for the practice.

An analysis of the group's billing compliance practices along with a review of the medical charts and billing records are reviewed to determine the appropriateness of the codes billed.

It has been our experience that in most instances the documentation in the patient's chart did not support the coding billed. In this situation or in a situation where it appeared that there were fraudulent billings submitted, we have helped to mitigate the damages due.

It is important for a practice to provide coding and documentation education for the physicians and staff, coding utilization reviews and a billing compliance program to lessen the chance of being audited.

Managed Care Payor Issues

The Healthcare Services Group has worked with numerous practices to determine damages against managed care companies for improper claims processing and payment procedures.

The areas that have been most prevalent are the processing of incorrect reimbursement to the provider based on their contract, re-caps taken by the insurance company in error, down-coding, late payments and inappropriate denials.

Physicians Working With a Management Company

Physicians have entered into contracts with a management company that failed to provide the proper billing services that would benefit the physician. The improper billing services varied from incorrect posting of charges, which created a large volume of claims denials, excessive and non-authorized adjustments incorrect fee schedules for one practice and fraudulent billing for another practice. This resulted in the management company continuing to bill their management fees in excess of the physician's collections per month.