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RAC Auditors and Insurance Companies Over-reach in Recoupment and Restitution Efforts

 

    WhatleyKallas is fighting efforts by health insurance companies and the government to obtain excessive amounts from physicians, hospitals and other providers through recoupment and restitution efforts. The calculation of excessive amounts frequently comes from improper statistical techniques, including extrapolation, during RAC audits and fraud and abuse investigations by private health insurance companies.  Recently, the United States Court of Appeals for the Fifth Circuit reversed $43 million in restitution ordered against two Houston-area physicians who pleaded guilty to defrauding health insurers, ruling the ordered amount exceeded the insurers' actual losses (United States v. Sharma, No. 11-20102, 12/20/12).  The restitution order was excessive because it included amounts unrelated to the specific offenses that the doctors had committed.  Nationwide, approximately half of the findings by RAC auditors are overturned by Administrative Law Judges on appeal. 

     WhatleyKallas counsels clients on avoiding conduct that might be considered fraud and abuse, including issues under the Stark and Anti-Kickback laws.  The firm also represents healthcare providers targeted by investigations and facing RAC, other governmental, and private insurer audits.