Expert Healthcare Audit Defense When It Matters Most
Receiving an audit can be overwhelming. Selecting the right subject matter experts as part of your defense team is the difference between a successful healthcare audit defense and adverse outcomes.
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Build a Winning Healthcare Audit Defense Strategy
At the root of any audit defense is a strong strategy. A winning strategy begins with a winning team, and collaboration between the client and our team is crucial.
You must have a sound strategy with experienced professionals who thoroughly understand the appeal process for all payers. Understanding what drives a level of service, what is required to support medical necessity, and how to defend clinical judgment is critical to the defensibility of your claims.
DoctorsManagement provides access to experts in auditing, compliance, coding and documentation, audit appeal, medical necessity, and statistical and post-audit extrapolation.
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A History of Successful Audit Appeals
We have a proven history of successful audit appeals. Our team of experts eliminates improper provider repayment demands across administrative, civil, and criminal proceedings.
Improper provider repayment demands eliminated annually
7 Count Indictment Reduced to 1
Seven count indictment reduced to 1 count of a class A misdemeanor.
22 Count Indictment Victory
Client found innocent on the 11 counts our experts testified on.
$11M Reduced to $3,000
Medicare refund demand reduced and payment suspension lifted.
$14M Reduced to $233
Medicare refund demand dramatically reduced through expert defense.
125-Year Suspension Dismissed
Case dismissed and provider fully reinstated after our defense.
Hundreds of Cases Won
Consistent track record of successful outcomes for our clients.
The Five-Step Medicare Part B Appeal Process
We can build a strong strategy to help navigate the appeal process. Understanding each step is critical to a successful outcome.
Redetermination With MAC
File a redetermination request within 120 days from the date you received the ERA or SPR. MACs generally issue a decision within 60 days of receiving the request.
120 days to file • 60 day decisionReconsideration With QIC
File a reconsideration request within 180 days from the date you received the MRN. The QIC generally sends a decision within 60 days. If not completed in time, you may escalate to OMHA.
180 days to file • 60 day decisionALJ Hearing at OMHA
File an ALJ hearing request within 60 days from the reconsideration decision. OMHA has 90 days to complete its review. OMHA prioritizes expedited Part D cases and appeals initiated by beneficiaries.
60 days to file • 90 day decisionMedicare Appeals Council Review
File a Council review request within 60 days from the OMHA decision. The Council generally decides within 90 days, or 180 days for escalated appeals.
60 days to file • 90-180 day decisionU.S. District Court Judicial Review
File a judicial review request within 60 days from the Council decision or after the Council decision time frame expires. A copy must be sent to all parties and the Council.
60 days to file • Federal court reviewTips to Bolster Your Healthcare Audit Defense
At the root of any audit defense is a strong strategy. Here are key elements that can strengthen your position.
Engage Counsel & Experts
Have counsel for the legal process and guidance for technical rules within 5-7 days of the original demand. Both need time to adequately work on your behalf.
Maintain Living Compliance Plan
The best defense is a good offense. A living compliance plan with annual payer updates, a known compliance officer, and confidential reporting puts you in a great position.
Understand Your Rights
There is always an option to challenge negative audit results. Ensure you and your counsel know the appeal steps and key factors at each stage.
Expert Defense Team Integration
DoctorsManagement provides access to experts who seamlessly integrate into your defense team. We can help healthcare providers protect against improper demands and flawed audit findings.
Help protect from recoupments based on auto-denials, auto-down coding, and over-aggressive audit findings
Offer regulatory compliance professionals, dual-certified auditors and coders, economists, statisticians, and clinical documentation experts
Engage as expert witnesses as part of your defense team in administrative, civil, and criminal proceedings
Auditing & Compliance Expertise
Deep knowledge of regulatory compliance, OIG guidelines, and payer-specific audit processes and requirements.
Coding & Documentation
Dual-certified coders and auditors who understand proper coding, medical necessity, and documentation requirements.
Statistical & Extrapolation Analysis
Economists and statisticians who can challenge flawed extrapolation methodologies and statistical sampling.
Expert Witness Services
Experienced professionals who can provide credible expert testimony in administrative, civil, and criminal proceedings.
Extensive Federal & Commercial Payer Experience
Our healthcare audit defense experts have extensive experience working at the highest levels with federal agencies and commercial payers.
Sean Weiss
Vice President, Compliance
Sean Weiss leads our audit defense practice with decades of experience in healthcare compliance, audit defense, and expert witness testimony. His expertise spans Medicare, Medicaid, and commercial payer audits at the highest levels.
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Facing an audit or investigation? Contact our team immediately to discuss your situation and begin building your defense strategy.
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DoctorsManagement does not work with patients. We offer support to medical practices.
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