A commercial payer audit or Medicare overpayment demand can arrive with little notice and put a provider’s revenue and standing at risk. A commercial payer audit & Medicare overpayment appeals lawyer can help at every stage.
A financial and health care compliance defense lawyer can review the audit file, compare the demand against the contract or Medicare rule at issue, and push back when the payer’s numbers do not match the record.
At Bertolino LLP, we have defended thousands of Texas providers and licensed professionals since 2003. Our Austin base puts us close to the agencies that govern their work. Reach out to our Client Success Liaison to schedule a complimentary consultation.
What Commercial Payer Audits Look Like in Texas
The first audit letter may look routine until the payer asks for records behind claims it has already paid. Once that review starts, the provider may have to defend the billing and the money already received against the payer’s reading of the file.
A private insurer can also look at the provider’s network agreement during the audit. If the payer claims the provider billed outside those terms, the dispute can move from repayment into credentialing or network participation.
A provider who receives a commercial payer audit notice has a limited window to respond before the payer finalizes its findings. The response at that stage can affect the scope of what the payer demands.
How Medicare Overpayment Demands Work in Texas
A Medicare overpayment demand usually starts with a contractor’s review of paid claims. The letter may come from a Recovery Audit Contractor (RAC) or a Medicare Administrative Contractor (MAC) and identify the amount Medicare says the provider owes.
The 60-day rule provides providers with a short window after an overpayment is identified. A provider that fails to report and return an identified overpayment may face False Claims Act exposure in addition to the repayment demand.
Interest accrues from the date of a Medicare demand letter, and that number grows while a provider considers their next step. A provider who contests the demand early gives themselves the best chance to limit what the government ultimately collects.
Common Reasons Texas Providers Face Audit Findings
Commercial payers and Medicare contractors look for specific patterns when they review provider claims. Some findings stem from billing errors, and others arise from documentation issues that the auditor treats as evidence of a broader billing problem.
Common issues that generate audit findings and overpayment demands include:
- Services billed without adequate clinical documentation.
- Incorrect procedure codes or evaluation and management (E&M) level assignments.
- Billing for services a payer considers medically unnecessary.
- Claims for services from unlicensed or improperly supervised staff.
- Duplicate billing or improper bundling of procedure codes.
- Missing orders, referrals, or prior authorization records.
An audit finding in any of these categories can lead to a repayment demand or a referral to a government agency for further review. What a provider puts on record at that stage can affect what comes next.
The Medicare Appeals Process for Texas Providers
Medicare overpayment demands go through a five-level appeal process. A provider can start with a redetermination request from the Medicare Administrative Contractor, then move to a Qualified Independent Contractor for reconsideration at the second level.
Cases that survive the first two levels can proceed to a hearing before an administrative law judge. If the dispute continues, the Departmental Appeals Board and federal court remain available as further appeal options.
The strength of each appeal submission depends on the documentation a provider presents to the reviewer. A provider who builds the record carefully at the early levels gives subsequent reviewers a stronger foundation to work from.
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How Texas Providers Can Contest Commercial Payer Findings
A repayment demand should send the provider back to the payer contract. That agreement controls the next step, including how the provider must challenge the audit findings before the payer treats the demand as final.
The appeal window in a commercial payer dispute can be short. A provider who misses that window may lose the right to contest the demand, and the deadline runs from the date the letter arrives.
Some payer contracts also include arbitration clauses that govern how a dispute is resolved after the internal appeal process ends. A provider who understands what their contract allows can build a stronger challenge from the start.
When a Texas Audit Leads to a Larger Investigation
An audit can take a different turn when the reviewer says the problem appears to be recurring rather than isolated. That finding may raise questions about who knew of the billing issue and whether the provider corrected it once the problem became known.
Those questions can pull the dispute into federal territory. If the government treats the claims as false, the provider may face False Claims Act liability in addition to the original repayment demand.
A provider should assume the audit record may be read by someone else later. The explanation provided early in the process needs to align with the documents and leave room for the defense if the case expands.
What a Commercial Payer Audit and Medicare Overpayment Attorney Does for Texas Providers
We start by reading the demand the way the payer or contractor wrote it. Then we compare that claim with the provider’s records and identify the point at which the audit overreaches.
We also look at whether the audit complied with the applicable contractor rules and timeframes. A provider who receives a demand based on a flawed audit process has grounds to challenge the findings before any discussion of repayment begins.
When a case reaches the appeal stage, we prepare the submission at each level and represent the provider if the dispute reaches a formal hearing. We challenge the demand on the facts the record supports.
Contact Our Texas Team About Your Audit
A commercial payer audit or Medicare overpayment demand can put a provider’s revenue and professional standing under simultaneous review. The response a provider builds at the start of that process tends to define how far it goes.
At Bertolino LLP, we have defended thousands of Texas providers and licensed professionals since 2003. We treat every audit response like the practice it protects, because that is exactly what is at stake. We don’t send form letters.
A commercial payer audit and Medicare overpayment attorney on our team is ready to review the demand and help you understand your options. Reach out to our Client Success Liaison to schedule a complimentary consultation.
Call or text (512) 515-9518 or complete a Case Evaluation form
