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Medicaid is defined by the Social Security Administration as “a jointly funded Federal-State health insurance program for low-income and needy people,” and goes on to say it’s for children, those without vision, those of a certain age, anyone with a disability, and anyone else who meets the strict and specific guidelines as created by federal law. Those with limited income are provided the opportunity to receive insurance benefits despite their inability to afford them, and Medicaid is accepted by hospitals, medical facilities, and pharmacies across the country.
Boston medical practices provide healthcare to those who use Medicaid as their insurance provider. One of the risks they run in using this program is a Medicaid Audit, which looks into various aspects of the patient, the doctor, and any other pertinent information. The reasoning behind a Medicaid audit is to minimize the amount of Medicaid Fraud in the United States. Billions of dollars are paid to claims that are false, misappropriated, or incorrect each year, adding significantly to the federal deficit. The government is cracking down on anyone who files false Medicaid claims, and Medicaid Audits are on the rise.
The Medicaid Integrity Program was designed to audit claims from doctor’s offices as they come into the offices. It’s been in existence since 2005, and the program uses Medicaid Integrity Contractors to review files, cases, and prove that each claim is acceptable, honest, and verifiable. When your practice is notified of a Medicaid Audit, it’s a terrifying experience. Your license could be called into question, your practice could be fined, charged with fraud, and you could face time in prison for each count of fraud if it’s determined your office is guilty. Even if the doctor is not the responsible party, it’s a terrifying thought.
What to Expect
The Medicaid audit process sounds more intimidating than it is. it only occurs if there is a question with any of the claims submitted to Medicaid. The file is flagged, an investigation is opened, and the auditor will ask your office to provide specific information. The end of the investigation comes with a letter of clearance stating no wrongdoing was found within the office, or a case is turned over to the court.
– Duplicate billing
– Charging for procedures not given
– Providing excessive procedures to specific patients
These are just a few of the things a doctor’s office might submit to the Medicaid department that could raise a red flag. In many instances, it’s found that a simple mistake was made rather than fraud. For instance, an office might have gone through an issue with their billing company, and the billing company and the office both submitted claims for several patients resulting in duplicate claims filed. Another common occurrence is a simple mistake made by administrative staff, such as inputting an incorrect Social Security Number or mixing up files when inputting patient information on a busy day. It’s frowned upon, but it’s not illegal to make a mistake when it’s corrected and realized.
Cases like this are easily proven. If the case shows fraud is occurring within the office following an audit, however, the doctor is subject to a number of disciplinary actions.
– Prison time
– Loss of license
Most Medicaid fraud cases charge an offender a maximum of $5,000 per charge in addition to up to 5 years in prison per charge. Depending on the number of charges a doctor’s office is found guilty of committing, a medical professional could face many years in prison, hundreds of thousands of dollars in fines, and complete restitution for all the money they defrauded the government for.
An experienced Medicaid audit attorney can help any Boston medical facility overcome fraudulent claims by working with the auditor to expedite the audit. Attorneys are familiar with the law, how to meet the expectations of the auditor, and how the help their client at the same time. If guilt is determined, an attorney can also negotiate less severe penalties, potentially even allowing for a reinstated license at some point if it’s determined the doctor is not the person to blame when administrative sanctions are issued.