Robinson+Cole helps health care providers confidently navigate the challenges of audits, compliance, administrative reviews, and appeals. Our team understands how stressful and disruptive these issues can be, and we are here to help protect what matters most — your reputation, revenue, and ability to keep serving patients. We take the time to understand your operations and tailor our legal strategies not only to resolve the issue at hand but also to strengthen your compliance moving forward.

Audit Defense and Strategic Response

Health care providers and entities are increasingly subject to audits from various government and commercial payors. We offer robust representation and guidance for Centers for Medicare & Medicaid:

• Provider audits
• Targeted Probe and Educate (TPE) audits
• Supplemental Medical Review Contractor (SMRC) audits
• Unified Program Integrity Contractor (UPIC) audits
• Medicare Administrative Contractor (MAC) reviews

Commercial Payor Audits

Our attorneys’ knowledge of regulatory requirements helps you respond effectively to audit requests, mitigate overpayment demands, and appeal adverse findings. If an audit results in an unfavorable determination, we can guide you through the various levels of the applicable appeals process — from submitting a redetermination to going to an administrative law judge or a contested case hearing and negotiating settlements. We work closely with providers and your compliance and billing teams to ensure a coordinated and timely response.

Our services include:

• Conducting pre-audit risk assessments
• Responding to audit notices
• Reviewing claims documents and developing a response strategy
• Challenging the factual bases and audit methodology underlying overpayment demands, including those based on extrapolated data
• Negotiating settlements or repayment terms when appropriate
• Appealing audit findings through administrative hearings or court proceedings
• Providing education and training to reduce future risk
• Guiding you through voluntary self-disclosures

If you think you may have discovered a billing issue or compliance concern, we can help you take the right steps — before it becomes a bigger problem. We guide you through voluntary self-disclosures to the appropriate agencies, helping you:

• Investigate and document the issue
• Submit a clear and accurate disclosure
• Negotiate repayment or settlement terms
• Put corrective actions in place

Being proactive shows regulators that you take compliance seriously — and we can help you do it the right way.

Conditions of Participation and Licensure Survey Response

If you are concerned about compliance with Medicare conditions of participation or are faced with negative survey findings, we can help you:

• Investigate and document the issues and root causes
• Develop and implement corrective action plans
• Respond to deficiency findings, including a Medicare termination action or immediate jeopardy finding
• Take affirmative steps to help avoid termination of a provider agreement, civil money penalties, or other sanctions against a provider or licensee
• Navigate provider investigations and licensure matters

We regularly counsel providers regarding licensure and administrative matters, including investigations into prescribing practices, disciplinary actions, and billing disputes. Our multidisciplinary can effectively guide you through these difficult matters.

Regulatory Approvals and Challenges

Members of our group  have extensive experience helping clients navigate the full range of certificate and determination of need processes, such as performing analyses of the applicability of such laws and regulations to specific projects and proposals (including in connection with mergers and acquisitions, expansions or terminations of services, and procuring equipment), preparation and submission of applications, representation in hearings before administrative agencies regarding applications (including contested hearings on behalf of both applicants and intervenors), settlement negotiations, and post-approval compliance monitoring.

We also represent health care providers in appealing the sufficiency of Medicaid reimbursement and in challenging agency policies and interpretations of statutes and regulations through declaratory ruling proceedings at the administrative level and in state and federal courts.