Managing a healthcare practice in New York comes with daily challenges. Being notified that their business is under review or about to be audited can lead one to ask, “What happens during a healthcare compliance audit in New York?” Weiss Zarett Brofman Sonnenklar & Levy, P.C., can help you avoid missteps that could harm your business.
Understanding Healthcare Audits in New York
Compliance audits aim to reduce wasteful or even fraudulent billing. Healthcare audits and reviews can originate from a variety of sources, including:
- Medicare and Medicaid contractors
- Private insurance payors
- Government agencies responsible for overseeing healthcare programs
These audits often focus on billing practices, coding accuracy, documentation requirements, and regulatory compliance.
While some audits are conducted as part of routine oversight efforts, others may be triggered by unusual billing patterns, patient complaints, whistleblower reports, or suspected violations of healthcare regulations. Serious cases of fraud can potentially lead to criminal investigations. In 2025, 66,662 cases were reported to the United States Sentencing Commission, and 340 involved healthcare fraud.
Not every healthcare audit involves allegations of fraud. Many audits begin as reviews of documentation, coding practices, reimbursement claims, or compliance procedures. However, an audit can lead to repayment demands, increased scrutiny or oversight, and referrals to other regulatory authorities when significant concerns are identified.
Government-conducted audits aim to reduce fraud. In 2024, Medicaid Fraud Control Units recovered $1.4 billion through 493 civil settlements, judgments, and other resolutions. Healthcare providers may encounter a wide range of audits throughout their careers. Common examples include:
- Medicare audits
- Medicaid audits
- HIPAA compliance reviews
- Telehealth audits
- Audits conducted by private insurance companies
As of 2024, there were 79,467 physicians in New York, and compliance issues can affect doctors in any field.
What Are the Steps Involved in a Healthcare Compliance Audit?
A healthcare compliance audit typically begins when a provider receives notice that records, billing practices, or compliance procedures are being reviewed. Auditors may request:
- Patient records
- Billing documentation
- Coding information
- Policies
- Other materials related to the services under review
After examining the documentation, auditors may seek additional information or clarification regarding specific claims or practices. Once the review is complete, the provider receives findings that identify any perceived deficiencies, compliance concerns, or reimbursement issues. Depending on the results, the matter may:
- Conclude without further action.
- Require corrective measures.
- Lead to repayment demands, disputes, or additional regulatory scrutiny.
Why You Should Hire a Healthcare Audit Defense Lawyer?
Whether your medical practice is located on the Upper East Side, Astoria, Jackson Heights, or another community in New York, facing a healthcare audit alone could lead to unfavorable outcomes. When you hire a healthcare audit defense lawyer, you remove the guesswork involved in the process.
Your New York healthcare audit defense attorney can manage your healthcare audit defense case based on their knowledge of healthcare audit laws and extensive experience in these cases. Healthcare audit lawyers can communicate with the other party on your behalf. That way, there are no miscommunications that could lead to further scrutiny.
By providing guidance and support at every step, your lawyer can streamline the process while reducing your stress. Weiss Zarett Brofman Sonnenklar & Levy, P.C., represents clients facing an audit. We provide focused legal support based on our many years of experience. When you work with our firm, you are connected to one of our skilled attorneys, who personally manages your case from start to finish.
FAQs
What Does a Healthcare Compliance Auditor Do?
A healthcare compliance auditor reviews a healthcare provider’s records, billing practices, coding procedures, and compliance policies to determine whether they comply with applicable laws, regulations, and program requirements. Auditors may examine documentation supporting claims that are submitted to Medicare, Medicaid, or private insurance companies. The aim of these formal reviews is to identify potential compliance concerns.
What Happens During a Compliance Audit?
A compliance audit typically begins with a request for records and other documentation. Auditors review patient files, billing records, coding information, and compliance procedures before issuing findings. Depending on the outcome, the audit may conclude without further action, or it could result in corrective measures. Repayment demands and additional reviews are also possible.
Can You Fail a Compliance Audit?
Yes. If auditors identify significant deficiencies, documentation problems, billing errors, or regulatory violations, they may issue adverse findings. Depending on the outcome of an audit, the healthcare provider could be told to repay unsupported billings. Serious concerns could lead to a more thorough audit and ongoing scrutiny or oversight by the group conducting the review.
Do I Need a Lawyer During a Healthcare Audit?
While healthcare providers are not always required to retain legal counsel during an audit, doing so can protect their interests throughout the review process. An attorney can:
- Respond to document requests.
- Communicate with auditors.
- Evaluate potential compliance concerns.
- Address disputes that arise from audit findings.
Legal guidance may be particularly valuable when an audit involves significant repayment demands.
What Can Trigger a HIPAA Compliance Audit?
HIPAA compliance audits may be triggered by:
- Data breaches
- Patient complaints
- Reports of unauthorized disclosures of protected health information
- Cybersecurity incidents
- Other concerns involving privacy and security practices
Some audits may also be conducted as part of broader compliance oversight efforts. HIPAA violations are considered serious offenses, and the outcome of a review could lead to future reviews.
If You Are Facing an Audit, Contact Weiss Zarett Brofman Sonnenklar & Levy, P.C., Today
Facing an audit can make you feel like everything is at risk. When you work with the dedicated and experienced healthcare audit attorneys at Weiss Zarett Brofman Sonnenklar & Levy, P.C., you gain the steady support of a legal team that cares about your case and about protecting what you have built.
Our law firm started as a mom-and-pop firm that grew due to our success over the years. We help healthcare providers navigate the complexities of regulatory compliance issues, including audits. At every step of the process, you can trust our lawyers to prioritize your interests. Contact our office today to schedule your consultation. We can provide the results-driven legal support your case deserves.
