Navigating Health Care Provider Audits and Investigations

Health care payors such as Medicaid, Medicaid Managed Care, Medicare, Medicare Managed Care and private insurance companies often audit and investigate health care providers who receive their funding. These audits and investigations can have potentially devastating financial consequences. You need highly competent and experienced legal counsel to represent your health care program if you are under audit or investigation. Your counsel will need to make every conceivable argument that they can make on your behalf to convince the auditors and investigators that they should not finalize the proposed disallowance(s).

Additionally, such audits usually involve sampling and extrapolation techniques which escalate small dollar amounts for disallowed claims in the audited sample to huge dollar amounts when projected across your entire claims universe. For example, a 20% error rate in the audited claims sample can mean a 20% repayment of all money paid across the entire audit period. These sampling and extrapolation techniques often result in astronomical repayment amounts.

Many health care payor audits use questionable, or even invalid, statistical sampling and extrapolation methodologies, and accordingly require the services of an expert statistician to rigorously evaluate such methodologies as part of your defense. Our firm has longstanding relationships with highly experienced statistical experts, and we retain such experts to assist in your defense.

Meet David R. Ross, Esq.

David R. Ross, Esq. is a Shareholder with our firm who has over 27 years of experience interpreting Medicaid regulations and various guidance materials issued by New York State regulatory agencies including the Department of Health (DOH), the Office for Persons with Developmental Disabilities (OPWDD), the Office of Addiction Services and Supports (OASAS), the Office of Mental Health (OMH). He also has over 17 years of experience dealing with the rules and guidance materials of the Medicare program, its contractors, and those of private insurance companies.

He has over 17 years of experience representing providers in various Medicaid, Medicare, and private insurer audits and investigations.

Before joining the Firm, Mr. Ross served as the Director of Audits and Investigations and the General Counsel of the New York State Office of the Medicaid Inspector General (OMIG).

Mr. Ross was also the Acting Medicaid Inspector General for the State of New York.

If you have questions or concerns regarding your health care program or business, and Medicaid, Medicare, or private insurance audits and investigations, contact David R. Ross, Esq. at or via telephone at (518) 312-0167.