Commercial Payer Audit Defense
Last updated on April 16, 2026
Commercial payers, such as insurance companies, hospital systems, pharmacies and other high-volume medical providers, can face considerable, unavoidable legal risks. At the commercial high-volume stage, discrepancies on a small level can become red flags, leading to intense scrutiny.
My name is Alejandro Mora, and I’m a health insurance audit defense attorney with over 20 years of experience. I take the lead on the complicated, high-stakes legal issues that face organizations in the health care industry. As your lawyer, I will provide your company stakeholders with confidence and assurance that they will go into an audit defense with a detailed plan and an assertive voice.
Common Red Flags That Trigger Audits
At the commercial level, discrepancies can cause anomalies in billing data that raise red flags for regulators, and enough red flags mean an inevitable audit. Here are examples of things that will inevitably trigger investigation:
- Suspicious billing patterns that could include high-cost items or high-value billing codes
- Upcoding trends
- Demographic data misuse or manipulation
- Rejections and corrections
What auditors look for are masses of data points that lead to a conclusion of bad acts on the part of the commercial payer. However, a selection of red flags does not always equal bad actors, bad acts and definitely not intentional fraud.
During an audit, I will be the main point of contact for the auditors, responsible for gathering and providing information, arranging internal interviews and any other action necessary. And, if the audit shows that there was a regulatory violation, I will take action, moving immediately to appeal.
Resolving Payer Concerns Before They Grow
Payer audits are one aspect that can cause health care organizations to reach out to me, but they are by far not the only ones. I am brought in by companies in situations of all types where the risk of audit and regulatory enforcement are very tangible and real, including:
- Recoupments and overpayment demands
- Enrollment and credentialing problems
- Network termination disputes
- Payment denials or underpayment issues
My services here are tailored to the needs of each of my clients, and while all of my clients face the same pressures of operational risk management, how they want to approach it may vary. I take the point on these problems, and help your company resolve problems effectively, and in a strategy you are comfortable with.
In-Depth Audit Representation
Audits of any type in any industry are high-effort challenges to resolve. There will be much more scrutiny than most companies wish to experience. I can help you manage these issues in real time. Call my office at 512-937-1128 today to learn more or send an email using this form.
