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Healthcare providers are subject to different types of audits based on the medical services they provide. Allegations of overpayment are raised by various Medicaid and Medicare audit contractors such as Recovery Audit Contractors (RACs) and Medicaid Integrity Contractors (MICs). Insurance companies usually initiate audits for overpayment. While each of these contractors is determined to detect fraudulent conduct and overpayment by health care services, each of them uses a different method of auditing. Therefore, medical practitioners need not assume that since they have dealt with one audit, that the same approach will be used in a different audit. Contractors also have varying approaches for seeking compensation. Consulting with a lawyer can help you tell the difference between various kinds of audits and the approach you should take for each one of them.
The Medicaid Integrity Program was initiated to identify, prevent, and punish Medicaid fraud. MIP audits focus on recouping overpayments, and detecting fraud, or error.
MIP is conducted by Medicaid Integrity Contractors (MICs) who perform audits and reviews to detect and recover improper payments. MICs work in conjunction with each state’s Medicaid authority to provide technical aid and oversight.
There are three types of MICs: review MICs, audit MICs, and education MICs. The review MICs determine the provider who should be audited by reviewing claims that date back to five years. The claim is then looked into by the audit MICs who write to the provider notifying them of the audit and requesting for records.
In the early phases of the audit, the audit MIC will arrange for an entrance conference with the provider. An audit can be a field audit or desk audit depending on the situation. Furthermore, an auditor can ask for a few or many records depending on the complexity of the case.
After the audit has been concluded, the audit report is presented to the state’s Medicaid authority for review and to determine if the state’s policies on Medicaid were adhered to. The report is later handed to the provider for a response. The provider is required to comment and provide additional information with respect to the audit report in 30 days.
Correctly responding to an audit questionnaire and providing complete, well organized, and responsive medical records are required after you are served with an audit report. The presence of a lawyer during this phase of the investigation is necessary if you are to avoid prosecution.
Recovery of Payments
The Medicaid program uses an extrapolation formula to calculate overpayments. Therefore, every dollar that is owed to you can amount to savings ranging from $50-$100 at the end of the audit. One of the goals of a Medicaid Audit lawyer is to present documentation that proves that accounts were billed and paid correctly.
MICs are not paid on a contingency basis nor are they charged with recovering overpayments. In cases where overpayments are noted, the state will get involved in collecting the amounts from the providers. The federal government will later receive its share of the recovered overpayments from the state. An appeal for MIC audit reports is subject to a state’s law and appeals process.
Fair Hearing in Medicaid Audits
Fair hearing is used to refer to an administrative hearing given to a Medicaid provider before their benefits are reduced, changed, or terminated. These hearings are in response to actions by the Medicaid Integrity Program, Department of Health, Agency for Health Care Administration, and other Health Care Agencies. Such hearings are not always fair, especially if the defendant does not have a lawyer. It is important to know the procedural rules of such proceedings and the case laws that have voided or interpreted Medicaid laws. Therefore, representing yourself would give the prosecution an edge over you due to your inexperience in the legal aspects of these cases. The presence of a lawyer helps you get a fair hearing and ensures that you have a good chance to uphold your rights and prove your innocence.
Penalties for Medicaid Fraud
Medicaid fraud can be prosecuted following an audit or a federal or state independent investigation. Since Medicaid audits and the appeal process involve interactions between the federal, state, and administrative law, it is advisable to consult a lawyer for a successful negotiation and to enforce your rights. Medicare overpayments and fraudulent practices can lead to severe consequences including civil suits, criminal prosecution, and exclusion from Medicare and Medicaid programs.