In today's complex healthcare landscape, medical providers face increasing scrutiny from government agencies and private insurers. When your practice receives notice of an audit, the stakes are high – your reputation, financial stability, and even your ability to continue practicing medicine may hang in the balance. At Varghese & Associates, P.C., our healthcare audit attorneys understand the intricate challenges medical professionals face during audits and investigations.

Contact Varghese & Associates, P.C. today for a confidential consultation with our healthcare audit attorneys who will evaluate your situation and develop a customized defense strategy to protect what matters most—your practice, reputation, and future.

What is a Healthcare Audit?

A healthcare audit is a formal examination of a medical provider's records, billing practices, and operational procedures conducted by government agencies (like Medicare, Medicaid, or the DEA) or private insurance companies to verify compliance with applicable laws, regulations, and contractual requirements. As healthcare fraud defense lawyers, we see these audits ranging from routine reviews to targeted investigations that scrutinize documentation, coding accuracy, medical necessity determinations, and prescribing patterns.

When representing healthcare providers, we understand that audits carry significant consequences including potential financial recoupments, prepayment review requirements, program exclusion, and in severe cases, civil or criminal liability. The audit process typically involves document requests, on-site inspections, provider interviews, and statistical sampling methodologies that require strategic legal intervention at each stage to protect our clients' practices, reputations, and professional futures.

How a Healthcare Audit Attorney in NYC Can Protect Your Rights and Your Practice

Our healthcare audit attorneys provide strategic legal defense when your medical practice faces government or insurance company scrutiny.

• Immediate Response: Our healthcare audit attorneys act quickly upon receiving audit notices, analyzing the scope and developing a tailored defense strategy to protect your practice from potential penalties.
• Documentation Review: Our healthcare audit lawyers thoroughly examine your medical records, billing documents, and compliance materials to identify strengths and address vulnerabilities before auditors do.
• Auditor Communication: Our healthcare audit attorneys serve as your official representative in all interactions with auditors, ensuring your rights are protected and preventing potentially damaging statements.
• Statistical Sampling Challenges: Our healthcare audit attorneys scrutinize the methodology used in extrapolated findings, often reducing alleged overpayments by challenging flawed sampling techniques.
• DEA Defense: Our healthcare audit attorneys protect healthcare providers facing DEA investigations related to controlled substance prescribing, dispensing practices, and regulatory compliance.
• Appeal Representation: We vigorously contest adverse findings through administrative appeals, reconsideration requests, and formal hearings to overturn improper determinations.
• Compliance Guidance: Our healthcare audit attorneys help implement robust internal protocols designed to prevent future audit triggers while maintaining efficient healthcare operations.
• Settlement Negotiation: When appropriate, we leverage our experience to secure favorable settlement terms that minimize financial penalties and practice restrictions.
• Medicare/Medicaid Audit Defense: We navigate the complex regulations governing federal healthcare programs to defend against allegations of improper billing or documentation.
• Private Payer Disputes: Our healthcare audit attorneys resolve contract interpretations and payment recoupment efforts by commercial insurers through effective negotiation and litigation.

When your professional reputation and practice viability are at stake, Varghese & Associates, P.C. provides the knowledgeable healthcare audit defense you need to navigate these challenges and secure the best possible outcome.

Healthcare Audit Cases We Take

At Varghese & Associates, P.C., our healthcare audit attorneys represent medical providers facing a wide range of regulatory investigations and compliance challenges throughout New York City and beyond.

• Medicare Fraud Allegations: Our healthcare audit lawyers defend providers against accusations of upcoding, unbundling, billing for services not rendered, and other alleged Medicare billing improprieties.
• Medicaid Audit Defense: Our Medicaid fraud defense lawyers navigate the complex web of state and federal Medicaid regulations to protect providers facing audits, payment suspensions, and fraud investigations.
• DEA Compliance Matters: Our DEA defense lawyers represent physicians, pharmacies, and other DEA registrants under scrutiny for controlled substance prescribing patterns, record-keeping requirements, and inventory controls.
• RAC Audit Challenges: Our healthcare audit attorneys contest Recovery Audit Contractor findings that improperly target legitimate billing practices through statistical sampling and extrapolation methods.
• ZPIC/UPIC Investigations: Our healthcare compliance lawyers defend against Zone Program Integrity Contractor and Unified Program Integrity Contractor audits focusing on suspected patterns of fraud, waste, and abuse.
• Private Insurance Audits: Our health insurance audit lawyers resolve disputes with commercial payers regarding contract interpretation, coding disagreements, and recoupment demands that threaten practice stability.
• OIG Exclusion Proceedings: Our healthcare defense attorneys fight to prevent providers from being excluded from federal healthcare programs following alleged regulatory violations or adverse audit findings.
• Self-Disclosure Protocol Guidance: Our healthcare compliance lawyers advise on strategic approaches to self-reporting potential violations while minimizing financial penalties and operational disruptions.
• Corporate Integrity Agreements: Our healthcare fraud defense attorneys negotiate reasonable compliance terms and monitor implementation requirements following government settlements.
• Whistleblower Defense: Our qui tam defense lawyers protect healthcare organizations facing lawsuits brought by current or former employees alleging False Claims Act violations.
• Nursing License Defense: Our nursing license defense lawyers represent nurses facing potential disciplinary action resulting from documentation issues, medication errors, or standard of care concerns identified during audits.
• Medical License Protection: Our medical license defense attorneys defend physicians whose licenses are threatened by audit findings suggesting improper care, documentation deficiencies, or billing irregularities.
• Pharmacy License Defense: Our pharmacy license defense lawyers protect pharmacists and pharmacy owners facing potential board discipline arising from controlled substance audits or dispensing investigations.
• Physical Therapy License Matters: Our physical therapy license defense attorneys represent therapists contesting audit findings related to supervision requirements, treatment documentation, or billing practices.
• Opioid Distribution Defense: Our opioid defense lawyers defend physicians, pharmacies, and pain management specialists facing heightened scrutiny over opioid prescribing patterns, defending against allegations of improper distribution while supporting legitimate pain management practices.

When your healthcare practice faces an audit or investigation, Varghese & Associates, P.C. brings the focused legal knowledge and strategic defense planning necessary to navigate these challenges while safeguarding your professional reputation and financial interests.

Consequences and Penalties of a Healthcare Fraud Conviction

At Varghese & Associates, P.C., our healthcare audit attorneys work diligently to prevent the severe repercussions that follow healthcare fraud convictions, which can devastate medical professionals personally and professionally.

• Imprisonment: Federal sentencing guidelines recommend substantial prison terms for healthcare fraud convictions, with sentences often ranging from 1-10 years per count and potentially longer in cases involving patient harm or significant financial losses.
• Monetary Penalties: Courts typically impose fines up to $250,000 for individuals and $500,000 for organizations per count, often accompanied by mandatory restitution payments for the full amount fraudulently obtained.
• Civil Financial Liability: Beyond criminal penalties, providers face civil False Claims Act liability of treble damages plus penalties that currently exceed $23,000 per false claim submitted to government programs.
• Permanent Program Exclusion: Conviction triggers mandatory exclusion from Medicare, Medicaid, and other federal healthcare programs for a minimum of five years, effectively ending careers for many healthcare providers.
• License Revocation: State licensing boards routinely initiate proceedings to suspend or permanently revoke professional licenses following fraud convictions, preventing practitioners from working even in private-pay settings.
• Asset Forfeiture: Federal prosecutors aggressively pursue forfeiture of assets linked to healthcare fraud, including personal property, real estate, bank accounts, and practice-related assets.
• DEA Registration Loss: Providers convicted of fraud typically lose DEA prescribing privileges, particularly when controlled substances played any role in the fraudulent scheme.
• Professional Reputation Damage: Convictions become permanent public record, appearing in database searches, news reports, and professional background checks for the remainder of one's career.
• Future Employment Restrictions: Many healthcare organizations and insurance networks permanently ban providers with fraud convictions from participation, severely limiting future practice opportunities.
• Immigration Consequences: Non-citizen healthcare providers may face deportation proceedings following fraud convictions, as these offenses typically qualify as crimes involving moral turpitude.

The devastation of a healthcare fraud conviction emphasizes why engaging experienced healthcare audit attorneys from Varghese & Associates, P.C. at the earliest signs of an investigation is critical to protecting your future through strategic defense planning and aggressive advocacy.

What To Do If Experiencing a Healthcare Audit

At Varghese & Associates, P.C., our healthcare audit attorneys recommend taking immediate strategic action when facing an audit to protect your rights and minimize potential consequences.

• Contact a Healthcare Audit Attorney: Call our experienced DEA defense lawyer team at Varghese & Associates before responding to auditors or submitting any documentation to ensure your interests are protected from the outset.
• Preserve Documentation: Immediately implement a litigation hold on all relevant medical records, billing documents, and correspondence to prevent any inadvertent destruction of potentially exculpatory evidence.
• Limit Communications: Direct all auditor inquiries to your healthcare audit attorney rather than attempting to explain or justify practices to investigators, as statements made without legal counsel may be misinterpreted.
• Document the Process: Maintain detailed records of all audit-related events, including dates of document requests, names of investigators, and topics discussed during any meetings or interviews.
• Review Internal Processes: Work with your healthcare audit attorney to conduct a privileged assessment of your compliance procedures, identifying any potential vulnerabilities before auditors discover them.
• Prepare Staff Properly: Allow your legal team to brief personnel who may be interviewed about their rights and responsibilities, ensuring they understand how to respond accurately without volunteering unnecessary information.
• Challenge Methodologies: Question statistical sampling techniques and extrapolation methods that may inappropriately inflate alleged overpayment amounts based on limited file reviews.
• Consider Self-Disclosure: Evaluate with your healthcare audit attorney whether a strategic self-disclosure might mitigate penalties if genuine compliance issues are identified during your internal review.
• Develop Correction Plans: Implement appropriate corrective actions for any legitimate deficiencies while maintaining that such changes do not constitute admission of wrongdoing or liability.
• Prepare for Appeals: Position your practice to contest adverse findings through the appropriate administrative channels, gathering supporting documentation and expert opinions to challenge erroneous conclusions.

Remember that early intervention by a qualified healthcare audit attorney often leads to better outcomes. Contact Varghese & Associates, P.C. at the first sign of audit activity to ensure your practice receives the comprehensive legal defense it deserves.

Get Experienced Defense When You Need It Most

When facing a healthcare audit, your immediate response can determine the outcome. Contact Varghese & Associates, P.C. today for a confidential consultation with our healthcare audit attorneys who will evaluate your situation and develop a customized defense strategy to protect what matters most—your practice, reputation, and future.

Healthcare Audit Attorney FAQs

What triggers a healthcare audit?

Healthcare audits are typically triggered by data analytics showing unusual billing patterns, patient complaints, whistleblower reports, random selection, or as part of targeted initiatives focusing on specific procedure codes or practice types.

How long do healthcare audits typically last?

The duration varies significantly based on scope and complexity, with routine audits potentially resolving in weeks while comprehensive investigations may continue for several months or even years in cases involving suspected systemic fraud.

Will my practice be shut down during an audit?

Most audits proceed without interrupting daily operations, though in severe cases involving allegations of patient harm or significant fraud, authorities may seek temporary suspension of billing privileges while the investigation proceeds.

Can I refuse to provide medical records to auditors?

While you have certain rights regarding the scope and manner of record production, outright refusal to cooperate with legitimate audit requests can escalate the situation and potentially trigger additional penalties or enforcement actions.

Are telehealth services subject to different audit procedures?

Telehealth services face heightened scrutiny regarding documentation of virtual visits, appropriate technology use, interstate practice compliance, and unique billing requirements that differ from traditional in-person services.

What happens if I've already spent the money that auditors claim was improperly paid?

Financial inability to repay does not eliminate liability, though our healthcare audit attorneys can often negotiate extended repayment plans or reduced settlements based on documented financial hardship.

How far back can auditors examine my billing records?

Most government auditors can review records going back six years, though fraud allegations can extend the lookback period to ten years or more in certain circumstances.