New York Medicaid Healthcare Audit Lawyers

Most doctors believe that they can never get audited by Medicaid, but you will be surprised to know that any healthcare provider can get audited. Thousands of practices and experienced doctors get audited each and every year by Medicaid; while others are audited by other health-related entities such as private insurance companies and Medicare. Although such circumstances may be frightening if you have never been audited before, experienced Medicaid healthcare audit lawyers can assist you to get through such a situation with your practice unharmed.

Medicaid Audit Procedure

A Medicaid Audit only happens if Medicaid has any reason to believe that you are improperly billing them or you are fraudulent. Therefore, they can decide to request you for all the documentation that was submitted. This means that you will only get audited if something in your billing is deemed fraudulent. This can be a particular case or a coding pattern. There are many and different ways that you can get flagged for a Medicaid audit, and most of them don’t necessarily involve fraudulent activities.

In most cases, the auditor asks for copies of certain documents and records. They will always give a list of the documents they need, usually, in the first letter they send announcing their intention to audit your practice. After submitting the requested records and documents, the auditor will assess them and determine if further investigation is necessary.

After the investigation, the auditor can send a clearance letter, meaning that Medicaid is satisfied that no incorrect billing or fraudulent activities occurred. In other cases, you can be subjected to repayment of overbilling, heavy fines, cancellation of your ability to bill Medicaid, and in some cases jail time. Most doctors who have successfully come out of Medicaid audits unharmed had the assistance of qualified Medicaid healthcare audit attorneys.

Reasons Why Most Doctors Get Audited

Medicaid fraud is increasing across the country, and this adds more billions of dollars to the medical expenses incurred by states every year. This has resulted in Medicaid taking strict measures to counter these fraudulent activities. In most cases, Medicaid will identify some billing practices that, although not fraudulent, they can indicate high possibilities of fraud. Therefore, if you commit any of these red flags, you will most likely be red flagged for a Medicaid audit.

Although very few doctors will often commit fraud intentionally, many can break the rules unknowingly. For instance, doctors billing Medicaid for procedures that were performed by nurses, and that required on-site supervision. These small hitches can eventually be exposed during an audit and eventually cause severe consequences.

What Can You Do After Receiving An Audit Letter From Medicaid?

The first and most important step after you realize that you are going to get audited by Medicaid is to read the letter carefully and get in touch with a qualified lawyer who has vast experience in this area. In most cases, the Medicaid audit letter will explain the reason as to why you are getting audited.

The letter will also contain the important documents that you are supposed to submit. Ensure that you submit these documents as soon as possible. Also, keep copies of all conversations with the auditor and any other persons involved in the audit. In some cases, your lawyer will advise you to submit more copies of the records and documents requested by the Medicaid auditor. This is especially if they can help to support your decision.

In case you are behind on paperwork, ensure you update them as soon as possible. However, remember not to make any changes to the existing documents. Most doctors are often tempted to expand their communication with their auditors to explaining their decisions, and this rarely ends well. Even making a slight change in existing records such as correct dating or adding any other correct information will make you look guilty.

How an Experienced Medicaid Audit Attorney Will Help You

Your Medicaid audit attorney will help you in several ways. First of all, your attorney will determine the reason as to why you are getting audited in case the auditor never made it clear in the letter. Secondly, your attorney will select documents that can assist in supporting your case. However, although it is necessary to submit all the files requested by the Medicaid auditor, the decision on whether to send more records will depend on your case.

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Your attorney will also assist you to locate the best coding consultant to support you. In case you decide to find your consultant, any mistakes in your coding can be exposed to Medicaid. On the other hand, a consultant hired by your attorney will legally withhold such information.

Legal Scenario: What Would You Do?

Scenario

You are a pediatrician in Brooklyn who just received a letter from the New York State Office of the Medicaid Inspector General notifying you that your practice has been selected for a full claims audit covering the past three years. The letter requests all patient records, billing documentation, and correspondence related to over 4,200 Medicaid claims your office submitted during that period.

What should I do immediately after receiving this Medicaid audit notification, and what are the potential consequences if they find billing irregularities?

Attorney's Answer

First, do not respond to the audit notice or turn over any records until you have retained an experienced healthcare audit attorney who can review the scope of the request and protect your rights throughout the process. Under New York Social Services Law § 145-b, if the audit determines that you submitted false or inappropriate claims, you could face recoupment of overpayments, treble damages, and exclusion from the Medicaid program entirely. In more serious cases involving alleged fraud, the matter can be referred for criminal prosecution under New York Penal Law § 177.05 through § 177.25, carrying penalties that range from a misdemeanor up to a Class B felony depending on the dollar amount involved. An attorney can challenge the audit methodology, negotiate settlements, and ensure that legitimate claims are not improperly denied during the review process.

This is general information only. Contact us for advice specific to your situation.

An experienced attorney will also know the tricks often used by Auditors. Therefore, they can foresee the arguments the auditor will use and plan on how to defend you. Although most doctors have never been audited, experienced attorneys have helped several practitioners.

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