From audit to fraud allegation
Medicare contractors review claims for medical necessity, documentation, and coding, and many disputes are resolved as overpayments through the administrative appeals process. Matters can escalate when reviewers see patterns that suggest intentional upcoding, billing for services not provided, or improper referral arrangements. The HHS Office of Inspector General, the Justice Department, and whistleblowers filing under the False Claims Act can all bring cases. Honest mistakes and negligence are generally not fraud; disputes usually turn on what the provider knew, and under the civil statute that can include reckless disregard of the truth.
Records and preservation
Keep patient charts, billing records, coding guidance, compliance policies, and communications with billing companies intact, and suspend routine deletion when an inquiry begins. Do not alter or supplement medical records after receiving a request; late entries can create serious problems. If you identify an overpayment, there are obligations to report and return it within a set period, so speak with counsel about how and when to do so. Employees who raise concerns may be protected by whistleblower laws, so internal handling of complaints requires care.
Decisions in the early stage
We look at the type of contact you received, the agency or contractor involved, and whether payments have been suspended. We discuss responding to records requests, conducting an internal review under privilege, and whether a self-disclosure may be appropriate. If there is any sign of criminal interest, we advise on how staff should handle contacts from investigators. We also consider effects on enrollment, licensing, and private payer contracts, since Medicare issues often spill over into other relationships. Some matters are really about documentation standards rather than intent, and recognizing that early can keep the response in the appeals process where it belongs.
