The number of auditors, reviewers, investigators, and prosecutors going after health care providers is increasing and signals an alarming, unprecedented effort by the government to uncover and recover alleged overpayments in order to reduce a runaway budget problem.

Providers now face not only simple reimbursement demand but also civil False Claims Act cases and criminal Medicare/Medicaid fraud claims identified by various new government contractors. Providers are judged by their adherence to rules that come from a variety of outlets and change without notice. CMS standards are truly a moving target. Regrettably we have seen unintentional mistakes, incomplete documentation and technical errors cited as the basis for seeking the repayment of millions of dollars. These orders to repay may represent Medicare services rendered long ago, in some cases many years before the demand letter was sent. Perhaps most troubling is the fact that no one, including the government investigators conducting the review, doubts that the medical services were rendered and in most cases the Medicare beneficiary benefited from the billed product or service provided. Today every health care provider must be aware of:

  • RAC's or Recovery Audit Contractors
  • MCFU Medicaid Fraud Control Unit
  • MICs Medicaid Integrity Contractors
  • HHS-OIG Department of Health and Human Services – Inspector General
  • DOJ U.S. Department of Justice
  • HEAT Healthcare Fraud Task Force

RACs and the havoc they wreak is nothing new. However the newest players in town ZPIC, MIC and HEAT Teams should be at the top of your list of concerns. These entities are designed to combine claim data and other data to create a platform for documenting complex data analysis. While RACs (until recently) have focused solely on recovery money, these other investigators also look at fraud.

All these agencies are revving up around the country and are unburdened by many of the restrictions placed on them previously. They are well aware that providers face many circumstances where there are opposing guidelines even on a single billing code. No matter which guideline you chose, you lose according to them. That's not fair.

Protect all that you have built by calling Khouri Law Firm at 949-336-2433. You’ll be able to talk to a healthcare-trained attorney free of charge to see if we can help defend your rights.