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
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