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Houston medicaid audits lawyers

November 18, 2016 Federal Criminal Attorneys

Most Houston medical facilities accept patients with Medicaid. It’s a state and government funded program for people with low-income situations, disabilities, or any other acceptable life situation that prevents them from being able to afford insurance otherwise. It’s a program that pays for medical procedures for those who can’t afford them, and it’s a program that’s defrauded out of billions of dollars every year. While some offices do engage in Medicaid fraud, others unintentionally make mistakes or even miss issues in their billing practices. This can result in Medicaid audits.

Audits occur when files are flagged as they are submitted to Medicaid offices. These files might indicate suspicion of fraud, whether it’s true or not. One a file is flagged, the medical facility it came from is investigated for Medicaid fraud. In a perfect world, the investigation turns up nothing more than a simple administrative mistake causing an incorrect bill to have been submitted or that nothing incorrect happened at all. In many cases, however, fraud is proven and doctors face fines, restitution, and potential prison sentences depending on the amount they received on fraudulent billing.

Medicaid audit attorneys in Houston have the experience it takes to help doctors when it comes to Medicaid claims. The law is complex and not always easily understood. Doctors have patients to focus on, and it’s not always a reasonable expectation a doctor can spend the time necessary to prove he or she is not guilty of committing Medicaid fraud when patients need their help. Attorneys are able to spend the time necessary providing proof that fraud was not committed so doctors can focus on their attorneys.

Red Flags in Medicaid Audits

The most common red flags include receipt of duplicate bills at the Medicaid office, excessive charges for just one patient, and excessive procedures recorded as performed on one patient in a short amount of time. On occasion, Medicaid facilities receive fraudulent bills for patients with falsified information such as Social Security Numbers, and even bills for patients that have been long deceased. Fraud is not always obvious, and sometimes it’s nothing more than a simple mistake.


Doctors and their administrative teams are imperfect. Additionally, their patients are imperfect. An office might be flagged for Medicaid fraud and audited because a patient came into the office and provided false information to the doctor’s office. It might not be something the office notices, but the federal government does notice. An administrative assistant might make a billing mistake, might make some patient record mistakes, or could be working on his or her own to commit fraud in the office. These things happen all the time, and it’s easily proven by a doctor and his legal team when mistakes caused the audit to occur.

If it’s proven the fraudulent charges were an administrative issue, doctors still have issues to deal with. Administrative sanctions are issued to offices, and doctors are fined for their negligence in being sure their administrative staff was doing their job with reasonable care. If money was defrauded, the office is still responsible for restitution, and the doctor in charge might end up with a citation, on probation, or with a suspended license.

Disciplinary Action

If fraud can be proven through the course of a Medicaid audit, there are many things that could happen to the doctor in question.

– Fines
– Restitution
License suspension
License revocation
– Probation
– Citations
– Administrative sanctions
– Prison time

It’s unclear how much prison time or how much money an office might pay in fines until the audit is complete. The maximum is $5,000 and 5 years in prison per offense, but Medicaid fraud usually encompasses multiple counts of fraud, which pushes the fines and the prison time possible for an doctor into much more. An experienced Medicaid audit attorney can help you prove your case, go through the audit without taking time from your patients, and guide you through the legal process when an audit occurs. Your chance of a successful outcome increases when you use an attorney with experience with Medicaid fraud cases, audits, and potential criminal investigations.



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San Diego medicaid audits lawyers

November 15, 2016

If you are a healthcare provider and your practice has come under scrutiny in a Medicaid audit, you need an experienced healthcare lawyer to represent you. At Raiser & Kenniff, we are experienced with healthcare law and we bring our expertise to the assistance of both sole practitioners and large medical practices. With all our experience, we have learned that there are many different types of Medicaid audits a healthcare practice can face. Different approaches are necessary for different types of audit depending on what organization or contractor is handling the audit.

The Medicaid Integrity Program and fraud prevention

Medicaid audits are conducted to make sure that healthcare providers are not engaging in fraudulent activity by overcharging Medicaid for services for a patient. The Medicaid Integrity Program was implemented to ensure that Medicaid fraud can be identified and prevented. However, there are many different audit contractors that could engage in fraud prevention efforts by initiating an audit. Just a few of the relevant medicaid auditors are Recovery Audit Contractors, Comprehensive Error Rate Testing programs, and Medicaid integrity Contractors. An audit can also be initiated by a private insurance company.

Thus, there are many different types of Medicaid Integrity Contractor out there. However, all of these contractors fall under one three categories. there exist review Medicaid Integrity Contractors, educational Medicaid Integrity Contractors, and audit Medicaid Integrity contractors. Each of these three different types of contractor serves a different purpose in the process of conducting an audit on a healthcare provider charging Medicaid.

Those who provide medical services need to understand the complexity of the audit process when it comes to Medicaid. Handling an audit for a client requires not only a knowledge of administrative law, but also an understanding of how state and federal law also combine to affect the administrative aspects of the case in question. An audit can have devastating consequences for a healthcare practice if it is not handled properly. Doctors and other healthcare professionals need to recognize the fact that their livelihood is on the line if they are facing an audit. Expert legal counsel is therefore of enormous importance.

Responding to an audit

The following are four important tips for healthcare providers who are currently facing a Medicaid audit and need to find legal counsel for assistance:

Act quickly- It’s very important to respond right away to an audit. Waiting until close to any due dates that go along with your audit can put you at risk of neglecting to include some vitally important information. Due dates are important for auditors and any required information must be sent in to The Agency For Health Care Administration (AHCA) by the due date to avoid penalties.

Acquire a copy of all submitted claims- Keeping careful records of Medicaid claims is important because of the possibility of an audit. When you face an audit, you need to be able to quickly and conveniently come up with documentation of all of your claims.

Single out and develop explanation on any particular patient record that might incite scrutiny- If you already know that certain claims might receive particular scrutiny, single out these claims and include written information that you can present to your legal counsel and to the AHCA when necessary.

Compile information necessary for the Medicaid Provider Questionnaire- The Medicaid Provider Questionnaire is necessary in responding to an audit. You’ll need to make sure that every section on the form is filled out before submitting it to the AHCA in response to your audit.

Of course, the most important thing to do after you have been notified that you’re being audited is contact us. We are a New York law firm specialized in healthcare law.

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