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In the state of New York allegations of Medicaid fraud are routinely investigated. These types of investigations are often conducted by the Office of Medicaid Inspector General (OMIG). This office will often start an investigation based on the findings from a routine audit. There are times when audits of Medicaid providers show a number of inconsistencies that attract attention. Some audit findings can result in disciplinary or criminal action and more. If someone is accused of negative behavior resulting from such an audit, they should obtain legal representation. This is a time to contact a New York lawyer who specializes in OMIG related issues.
OMIG are experts at detecting schemes designed to commit Medicaid fraud. Their goal is to increase the quality of Medicaid by eliminating abuse and waste. The investigations they conduct are designed to detect any providers who commit fraud or abuse of the system. Should abuse or fraud be identified, it may cause an administrative action to be taken as well as a referral for civil or criminal investigation.
Many audits are done randomly. There are also a large number of audits that result from an insurer’s system providing more than one red flag. This could be something like an unusually high service volume. This gives the appearance of services being over-utilized. Excessive use of a particular CPT code to document different patient treatments is another red flag. It is understood that patient treatment will involve a variety of things, which should result in a variety of codes. An increase in the amount of code modifiers is also a red flag. This may indicate a number of services were provided for a patient that exceeded care for their condition.
The goal of this audit is to identify any instances where an overpayment has occurred for services provided. This type of audit is initiated after certain red flags are identified. It could also be done as part of a random audit or as part of an effort to decrease spending on healthcare. An overpayment of services is not automatically considered fraud. In many cases, these errors can result from clerical mistakes, changes in cost for a service and more. This situation can often be resolved by having the overpayment be repaid. If there are inconsistencies discovered, the entity being audited will be given a notice. Response to this notice should be done as soon as possible.
When an audit reveals what appears to be criminal activity, an investigation will be conducted by state and federal law enforcement officials. This type of investigation is often the result of evidence showing illegal activities like fraud. The investigation could be the result of audit findings, a tip-off from an employee, patient, colleague and more. Law enforcement agencies have developed sophisticated methods for identifying illegal activities. They can obtain and carefully examine data from submitted claims that appear to be part of a fraudulent billing pattern. This type of investigation can have serious consequences. Anything said to investigators can be used to the provider’s detriment during the investigation. When an entity is the subject of such an investigation, they should speak with an experienced OMIG attorney immediately. They will know how to respond and provide the desired information and records.
If an entity is found guilty of Medicaid fraud, there are a number of administrative actions that may be taken. This includes being excluded from providing services under the Medicaid program. There could also be monetary penalties imposed as well as the recovery of Medicaid funds and more. It’s also possible for the fraud to be serious enough that it will be referred to the New York State Office of the Attorney General’s Medicaid Fraud Control Unit (MFCU). This department will conduct an investigation to determine if criminal prosecution is necessary. Depending on the situation, the case can also be referred to other government agencies including the Bureau of Narcotic Enforcement, Office of the Welfare Inspector General and others.
Avoiding Audit Problems
In order to avoid audit problems, an entity needs to regularly review their billing and coding practices to ensure they are compliant with the latest New York state law. This will help with compliance and when submitting claims. It is also possible for the uncommon operating methods of certain practices to cause an appearance of not being compliant with the law. This will often result in suspicion of the Medicaid provider. When this is the case, these entities need to make extra efforts to correctly substantiate and document the accuracy of their submitted claims. Developing an effective process for following the rules is the best way to avoid any problems with an audit. If an entity has any questions about a situation they are facing in regards to compliance, they should speak with an OMIG attorney. They will be able to explain how the law would interpret the billing methods they are using and provide advice on how to avoid problems.
Avoid Negative Consequences
When an entity is prohibited from providing services for the Medicaid program, they can experience financial, professional and other types of harm. It could ruin the careers of people working in the healthcare field. If subjected to an audit or any type of investigation by the OMIG, the goal is to avoid making any mistakes that could lead to long-term consequences. Speaking with an experienced OMIG attorney can prevent a bad situation from turning into an impossible one.