NYC Healthcare Audit Attorney

A healthcare audit can turn into a demand to repay large sums, a referral for fraud prosecution, or exclusion from Medicare and Medicaid, often based on a small sample of claims that auditors extrapolate across all of your billing. Providers face audits from Medicare and Medicaid contractors, from commercial and managed-care insurers, and from state agencies, each with its own rules, deadlines, and appeal rights. How you respond to that first audit letter shapes everything that follows, including whether the matter stays civil or becomes criminal. Because much of an audit dispute is about documentation and statistics, these matters are frequently defensible, but only with the right lawyer and an early response. If your practice is facing an audit in New York City, an experienced healthcare audit attorney should be your first call.

Varghese & Associates, P.C. is a federal criminal defense firm on Wall Street, in the heart of the Southern District of New York. Audit defense is a core part of our healthcare fraud defense practice, and the firm is led by Vinoo Varghese, a former prosecutor and one of the most recognized criminal defense attorneys in the country. Our healthcare audit attorneys handle these matters in house, from the first audit letter through the overpayment demand, the appeals, and any fraud investigation that follows. Matters are not routed out to other firms.

Call now for a confidential consultation with a New York City healthcare audit lawyer. The earlier our healthcare audit defense lawyers are involved, the more they can do.

What Is a Healthcare Audit?

A healthcare audit is a review of a provider's claims, medical records, and billing by a government program or insurer to determine whether payments were proper, and it can result in a demand to repay alleged overpayments, a referral for fraud prosecution, or exclusion from a program. An audit is not the same as a fraud charge, but it can lead to one. Treating an audit as routine paperwork is a serious mistake, because the provider's records and responses become the foundation for whatever comes next. Understanding what the auditors are looking for, and responding correctly, is the first step in protecting your practice.

What Types of Healthcare Audits Are There?

Healthcare audits include Medicare audits by contractors such as MACs, RACs, and UPICs, Medicaid audits by state agencies like the Office of the Medicaid Inspector General, and commercial or managed-care insurer audits, and they can be prepayment or postpayment reviews. Each type has its own procedures, deadlines, and appeal rights, and the risk level varies. A commercial payer audit may seek recoupment, while a government program-integrity review can signal a fraud investigation. For the program-specific process, see our Medicare audit defense and Medicaid audit defense pages.

Why Is Extrapolation So Important in a Healthcare Audit?

Extrapolation is the practice of reviewing a small sample of claims, calculating an error rate, and projecting that rate across all of a provider's billing, which can turn a handful of disputed claims into a demand for hundreds of thousands or millions of dollars. Extrapolation is where many healthcare audits are won or lost, because the statistical methods used are open to challenge. If the sample was too small, not properly random, or wrongly analyzed, the entire extrapolated demand can be undermined. Our healthcare audit attorneys work with statistical and clinical experts to attack flawed extrapolation and reduce the demand to what the actual claims support.

What Happens After a Healthcare Audit?

After a healthcare audit, the auditor typically issues findings and an overpayment demand, and the provider has a limited time to respond, submit additional documentation, and begin the appeals process to challenge the findings. A strong response can reduce or eliminate the demand by supplying documentation the auditors overlooked, correcting factual and coding errors, and challenging the extrapolation. Interest can accrue, and recoupment can begin if deadlines are missed, so acting quickly matters. The provider's early choices shape both the financial exposure and the risk of a fraud referral.

When Does a Healthcare Audit Become a Criminal Case?

A healthcare audit becomes a criminal case when auditors or investigators conclude that the billing problems reflect intentional fraud rather than error, and they refer the matter to prosecutors. The line between a civil overpayment and criminal fraud is intent. That is why what you say to auditors and how you respond to the audit matters so much, because casual statements or altered records can push a civil matter across that line. Certain government program-integrity audits in particular signal fraud suspicion. Keeping an audit civil, and out of the hands of criminal prosecutors, is one of the most important things a healthcare audit attorney can do.

What Are the Consequences of a Healthcare Audit?

The consequences of a healthcare audit can include repayment of alleged overpayments with interest, penalties, recoupment against future payments, referral for civil False Claims Act liability, exclusion from Medicare and Medicaid, and, if fraud is alleged, criminal prosecution. For many providers, an exclusion or a large repayment demand is a practice-threatening event on its own. Because these consequences build on the audit findings, the most effective time to influence the outcome is early, while the audit is still being conducted and before the findings harden into a final demand or a referral.

What Are the Defenses in a Healthcare Audit?

Healthcare audits turn on documentation and statistical methods, and that is where the defenses concentrate. Every matter is different, but the strategies our healthcare audit attorneys commonly use include:

• Producing the documentation. Supplying records that support claims the auditors marked as unsupported.
• Challenging extrapolation. Attacking the sample size, randomness, and statistical methods behind the projected demand.
• Medical necessity. Showing the services were appropriate and supported by clinical judgment.
• Correcting auditor errors. Identifying misread records, wrong codes, and factual mistakes in the findings.
• Distinguishing error from fraud. Demonstrating that any billing problems were good-faith mistakes, not intentional.
• Meeting every deadline. Preserving appeal rights at each level of the process.

What Should You Do If You Receive a Healthcare Audit Letter?

If you receive a healthcare audit letter or a records request, do not ignore the deadlines, do not submit records or talk to auditors without reviewing everything carefully, and do not alter or create any records. Call a healthcare audit attorney immediately. How you respond to the initial request shapes the entire audit, and altering or backdating records can turn a civil audit into a criminal case. Gather and preserve your documentation, and let your lawyer manage the response, the appeal, and communications with the auditor. An organized, well-counseled response is the single best way to control the outcome.

How Our Healthcare Audit Attorneys Can Help You

Our healthcare audit defense lawyers defend these matters at every stage, and they look for the earliest possible point at which the demand can be reduced or eliminated:

• Managing the audit response. Handling records requests and communications so the provider does not make the situation worse.
• Attacking extrapolation. Working with statistical and clinical experts to challenge the sampling and projected demand.
• Handling the appeals. Preparing and presenting the case through each level of the applicable appeals process.
• Keeping it civil. Working to prevent an audit from turning into a fraud referral, and defending any criminal exposure if it does.
• Protecting enrollment and licensure. Coordinating the audit defense with program exclusion and licensing consequences.
• Negotiating resolution. Seeking settlements that resolve the overpayment on manageable terms.

How Much Does It Cost to Hire a Healthcare Audit Lawyer in New York City?

The cost of a healthcare audit lawyer in New York City depends on the size of the audit and overpayment demand, the payer involved, the volume of records, whether expert extrapolation analysis is needed, and how far the appeal proceeds. These matters involve extensive record review, statistical analysis, and appeal preparation, so they require real work. Our healthcare audit attorneys are transparent about fees from the first conversation and structure the representation to fit the matter. Given that the demand, your program enrollment, and the risk of a fraud referral are all at stake, the more important question is usually what an inadequate response can cost you.

A Healthcare Audit Attorney the National Media Turns To

When the biggest federal cases in the country are in the news, networks and newspapers call Vinoo Varghese to explain what is really happening in the courtroom. That is the same judgment and credibility our healthcare audit attorneys bring to your case.

Vinoo Varghese has provided legal analysis and commentary for CBS News, Fox News, Fox Business, CNN, MSNBC, Court TV, HLN, BBC, Inside Edition, i24 News, Sky News Arabia, and Nancy Grace's Crime Stories, and has hosted true-crime legal analysis for Vanity Fair. He has been quoted as a legal authority by The New York Times, The Wall Street Journal, the New York Law Journal, Law360, the New York Daily News, and the New York Post. A former prosecutor from the Brooklyn District Attorney's Office, he is a nine-time National Trial Lawyers Top 100 honoree, an eight-time New York Metro Super Lawyer, rated AV Preeminent by Martindale-Hubbell, and has served on the visiting faculty of Harvard Law School's Trial Advocacy Workshop.

Contact a New York City Healthcare Audit Attorney Now

If you have received a healthcare audit letter, an overpayment demand, or a records request from a Medicare contractor, a Medicaid agency, or a commercial insurer anywhere in New York City, do not wait and do not respond on your own. A healthcare audit attorney who has stood in the courtroom and handled these matters can change what happens next.

Call Varghese & Associates, P.C. for a confidential consultation. Our office is located at 2 Wall Street, Suite 310, New York, NY 10005, steps from the federal courthouses of the Southern District of New York.