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