Health Care Litigation - Coding and Documentation Audits

Coders Day
September 2009

Coding and Documentation Audit 


  • Overview of Coder’s role in HC litigation
  • Case Study #1
  • Case Study #2
  • Case Study #3
  • Conclusion

Coder's role in HC litigation 

  • Coding specialist
  • Gather evidence for HC attorney
  • Expert witness in Court

Case Study #1 


  • Medicare sends an audit letter to the practice
  • No indication of the reason for nonpayment
  • Payment for all Medicare services stopped
  • Practice retains HC legal counsel
  • Legal counsel retains EisnerAmper

Results of EisnerAmper Review

  • All office visits billed at levels 4 or 5
  • Numerous lab tests per patient per visit
  • Numerous procedures at every visit
  • Numerous high risk diagnosis at every visit
  • Medicare nurse reviewers requested additional documentation to complete their review
  • Additional documentation supplied to Medicare
  • Medical Director states he has a medical necessity concern even though documentation is complete
  • Audit is disruptive to the practice’s cash flow
  • Importance of a Compliance Program
  • Billing Company role for documentation
  • Managing partner to discuss clinical approach with Medicare’s Medical Director
  • Healthcare attorney involvement for all discussions with Medicare
  • Numerous coding and documentation corrections noted to the practice by EisnerAmper

Outcome of Efforts

  • Negotiated settlement with Medicare
  • No Fraud indictments issued
  • Practice no longer services Medicare patients

Case Study #2 


  • Private payor audit regarding consultations
  • Payor requested an overpayment request in excess of $500,000 from the practice
  • Payor threatened fraud indictment
  • Practice retained HC legal counsel
  • Legal counsel retained EisnerAmper

Results of EisnerAmper Review

  • Consults billed for all visits including new and established visits
  • Frequent and repetitive administration of testing procedures
  • High number of procedures performed on family members
  • Diagnosis did not support level of office visit or medical necessity
  • Practice invested in an electronic medical records system – HC attorney suggested to use this investment as a defense against the payor
    • Inadequate documentation for any visit
    • Missing patient chart information
    • Missing documentation of procedures

Outcome of Efforts

  • Overpayment request by payor reduced by 40%
  • Physician no longer serviced patients from payor
  • Fraud charges not brought against physician
  • Physician sold practice

Case Study #3 


  • Physician sued by an imaging management company for overpayment of professional services
  • Portrayed as a contract dispute between management company and the physician
  • Physician retains HC legal counsel
  • Legal counsel retains EisnerAmper

Results of EisnerAmper Review

  • Management company billed global charges under the physician’s provider number
  • One owner of management company debarred from Medicare, but company continued to bill
  • Billings under the physician’s name after he retires
  • The same series of ultrasounds and/or echocardiograms were performed on all patients
  • Numerous billings for family members
  • Incorrect reporting of diagnosis or procedures to maximize payments
  • Billings also submitted incorrectly to all private payors

Outcome of Efforts

  • HC attorney turned over EisnerAmper findings to U.S. Attorney’s office
  • Criminal charges brought against owners of imaging management company
  • Physician was not required to return any overpayments requested by the management company


  • Fraud and abuse is prevalent in healthcare
  • Coder plays a key role in the proper billing of services
  • Coder assists legal counsel defend providers in requests for overpayments
  • Essential for all healthcare organizations to have Compliance Programs
Have Questions or Comments?

If you have any questions about this media item, we'd like to hear your opinion. Please share your thoughts with us.

Contact EisnerAmper

* Required