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While many healthcare providers are focused on getting through a Medicare Recovery Audit Contractor (RAC) program, they may overlook the other government insurance program: Medicaid. Just like Medicare, Medicaid has an audit system to which providers must answer if certain practices raise suspicions.
The Medicaid Integrity Program (MIP)
Typically, MIP continues the effort of trying to detect, enforce and prevent fraud and abuse in the system. Implemented through different Medicaid Integrity Contractors (MIC), MIP is Medicaid’s system through which audits and reviews of healthcare providers are conducted. The contractors in this program work with local state Medicaid agencies to provide oversight and technical assistance in administering the program.
Under provisions of the MIP, MICs are divided into three different categories based on their main tasks: review, audit, educate. Review MICs may look back as far as five years to identify providers for audits and potential claim reviews.
Handed over to an audit MIC, this person notifies the provider of a pending audit. They also request documents related to the claims in question. During early stages of the audit, the healthcare provider also has an entrance conference with the MIC.
Concluding the Audit
Once the audit concludes, the state Medicaid agency receives a draft report of the audit MIC’s findings. This gives the agency time to review the findings and comment on whether policies were followed correctly. Afterward, the report is sent to the provider for his or her comments and additional information to be submitted within 30 days.
What makes MICs different from Medicare RACs is MICs are not compensated based on how much in overpayments are recovered from their audits. In fact, they are not responsible for collecting the overpayments. Nevertheless, their findings do carry weight and can determine what happens next with your practice concerning participating in the Medicaid program.
Receiving a Demand for Payment
More often than not, Medicaid audits result in assessments against providers for tens of thousands of dollars. These amounts include overpayments, fines, penalties and interest.
When overpayments are identified, the state steps in to collect the money. Additionally, the federal government will get its share directly from the state.
After receiving a demand for the return of an overpayment from the Medicaid program, some providers might have a chance to negotiate the repayment or reach a settlement with more favorable terms. The odds of this occurring is even greater when Medicaid providers have competent legal representation.
There is even a possibility for the provider to appeal the MIC audit determination. This process is governed by state law and its appeals process. While an attorney may not appeal the entire decision, they may target the amount owed.
State Medicaid programs generally use a formula to calculate overpayment amounts. Appealing the determination can prove that some of the amount was miscalculated. Therefore, providers have the option to produce sufficient documentation that will disprove what is owed. For every dollar saved, the final amount could be greatly reduced. Some providers may even avoid a penalty assessment.
Following the auditor’s determination, Medicaid fraud can also lead to criminal prosecution. An independent investigation by state or federal authorities could lead to this even if the audit determines no fraud occurred.
In this type of scenario, the provider will usually receive a subpoena or search warrant to turn over records related to the Medicaid criminal investigation. The provider will want to have an attorney review the details of the subpoena and advise on the best way forward.
Having a law firm that is very familiar with the prosecution side of a criminal investigation gives providers a unique advantage. This type of experience arms attorneys with better defenses to help their clients resolve the case before charges go far enough to tarnish their reputation in the medical community.
Experienced Austin Medicaid Audit Lawyers
Raiser & Kenniff, PC has highly experienced lawyer who will aggressively defend clients who face a Medicaid healthcare audit. We use our knowledge of the process, from the initial audit all the way to appealing the decision, if necessary.
Healthcare providers can depend on us to assess their case. Our advice is based on specific factors and will present the best course of action to defend and win.