Medicaid is a government program that allows people who don’t have a large income to go to the doctor or to receive testing that they otherwise wouldn’t be able to afford. It can also be used to help pay for stays in the hospital or a nursing facility. Unfortunately, there are some concerns with medical offices when they have to audit doctors and other providers who tend to try to get more money from Medicaid.
A healthcare law firm represents everyone from dentists to hospitals who are involved with investigations and litigations. There are several issues that need to be addressed if someone is under an investigation with a Medicaid audit. The license of the doctor or nurse could be at risk as well as the license to operate at the office, nursing facility or the hospital. If the license is taken away, then the location would need to close until the issues have been remedied. Complete and organized records must be turned in to the audit team, and an attorney can help to ensure that these forms are completed like they should be so that the provider stands a better chance of remaining in business.
If a Provisional Agency Audit Report is received, it’s even more important to have all of the paperwork in order so that multiple payments to Medicaid are not made. This is a time to submit explanations for miscalculations, mistakes and other issues that have been reported. There are times that a demand for an over-payment might be requested. If the office or the provider has to pay back any money that has been received because there have been issues with getting more money from Medicaid, then it needs to be submitted as soon as possible so that it can be taken off of the record.
One of the ways that offices can get more money from Medicaid is to bill for multiple services that are provided when there is only one or two services that have been provided to patients. Some pharmacies will charge Medicaid for an expensive prescription while dispensing one that is less expensive. There are times when a pharmacy will bill for a medication that is expensive and give a patient that is completely different and cheaper but does the same thing as the one that is prescribed. Some doctors will submit codes for multiple services that were performed when they are supposed to submit combined codes. This is one of the common ways to get more from insurance companies like Medicaid. Most billing forms will combine common services, such as x-rays or blood work. The office would simply record individual services on multiple forms and change the date, making it look like there were several services that were provided for the patient on different days in order to get more money. If the patient doesn’t get a copy of the billing information from Medicaid, then the patient would never know that this was done.
Each dollar that is owed needs to be accounted for, and if the money can be shown, then it can end up saving the office hundreds in the final auditing process. This is where the attorney will be a benefit. The attorney can make sure the numbers that are recorded as they should be and that there are no errors with additions or subtractions. Other errors can also be discovered when the attorney looks at the paperwork that is submitted to the audit defense office. It could be something as simple as a number that needs to be changed or information about inventory that needs to be updated.
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If you just found out that your Medicaid claims are going to be audited, you need experienced legal advice for the best possible outcome. As a healthcare professional, it can be worrisome to have an audit, but it’s important that you understand that getting audited is a standard procedure. Don’t take your audit as some sort of accusation. Chances are, you will have no problems. However, working with a Medicaid healthcare audit lawyer is the best thing you can do to be successful.
There is a procedure that you need to go through to deal with an audit. Some of the tasks that you’ll need to carry out to get through the process could be cumbersome and distract you from your everyday job responsibilities. That’s just one more reason why it’s best to leave the job to a specialized legal professional.
Why are Medicaid audits carried out?
The purpose of an audit of Medicaid claims is to make sure that you’ve been charging Medicaid accurately and fairly on behalf of the medical services you’ve offered to your patients. Audits prevent fraud and allow the Medicaid program to avoid unnecessary expenses that inflate its costs. The way to get through an audit with success is to demonstrate that you have never filed a claim to Medicaid that inappropriately charged the program for medical care.
The business of Medicaid audits is sometimes confusing due to the fact that many contractors are responsible for these audits. Some contractors do business a little differently than others. As a healthcare practitioner, you can’t assume that you’ll be fine on an audit because you’ve already successfully handled an audit independently in the past. While a healthcare practitioner doesn’t have the specialties to recognize the habits and practices of a particular contractor, an attorney specialized in Medicaid audits does.
Regardless of the contractor you’re dealing with, you should know that it’s possible that the contractor will be very eager to recover Medicaid funds. Hopefully, you run your own occasional audits at your facility to make sure that you’re always charging Medicaid appropriately and accurately. When audits happen, record keeping becomes more important than ever.
Have you just recently received notification that your Medicaid claims are going to be audited? You should be aware of a few things before you get started to ensure that you come through the audit with no issues:
There are quite a few different organizations out there with which you might be dealing with- One of the most important things you’ll need to discuss with your lawyer is which contractor is responsible for the audit. Also, you’ll need to be aware of whether that contractor is a government contractor or a private payor contractor. Some of the different contractors you could potentially be dealing with are Quality Improvement Organizations, Medicaid Integrity Contractors, and Recovery audit contractors.
One of the most important things you’ll need to send in is a list of all your Medicaid claims- Again, records are very important when you’re audited. The quicker you can come up with a list of your Medicaid claims, the faster you can deal with the audit. You’ll need to put together a list of claims and how much was charged at each of these claims.
Getting to work on the audit right away is important- Don’t delay once you find out about an audit. Deadlines are important, and you could face fees or deeper scrutiny if you stall about responding to your audit. When reviewing documentation, make sure to find all due dates and mark them on your schedule so that you can stay on top of them.
You should discuss your responses to the Medicaid Provider Questionnaire with an attorney- You’ll get a Medicaid Provider Questionnaire with your audit. It’s not a good idea to submit this before you’ve discussed all the information you’re providing on it with your attorney.
Depending on the type of services, health care providers are likely to face some type of audit throughout the existence of their practice. This is especially true when accepting payment for Medicaid patients.
This government insurance program established the Medicaid Integrity Program (MIP) to detect, prevent and penalize fraud. Specifically, audits under this program are performed to detect fraud or errors and recoup overpayments to a health care facility.
Medicaid Integrity Contractors (MICs) implement this integrity program by conducting review and audits to identify and recover payments that were improperly made to a healthcare provider. Generally, MICs will work with the state’s Medicaid agency to provide technical assistance and oversight throughout the audit process.
Under provisions of the MIP, the Centers for Medicare and Medicaid Services hires contractors to conduct audits and review claims. Contractors will also educate Medicaid providers on the proper way to be compliant when submitting Medicaid claims.
Medicaid Audit Process
Medicaid Integrity Contractors are divided into three separate groups based on their primary tasks:
• Review MICs
• Audit MICs
• Education MICs
Review MICs are charged with identifying which providers to audit. They may review claims that are as old as five years. Next, audit MICs notify providers that an audit is scheduled and requests records. During the early stages, the provider has an entrance conference with the contractor who will perform the audit.
Depending on the specific reason an audit was triggered, the review process can be a field audit or a desk audit. The contractor can request as many records necessary.
Once the audit is completed, a draft audit report is submitted to the state Medicaid agency for its comments and review. The state agency determines whether Medicaid policies were followed correctly. Afterward, the report is sent to the provider for additional information and comment about the results. The provider has 30 days to submit a response.
MICs are different from Medicare recovery audit contractors because MICs are not compensated based on how much in overpayments the MICs are able to collect. In fact, MICs are not responsible for recovering overpayments.
Rather, the state Medicaid agency steps in to collect the overpayments that were identified during the audit. The federal government collects its share of overpayments from the state.
Handling an Audit Alone is Admirable, but…
For various reasons, providers may want to handle the audit on their own. Most notably, they know they have done nothing wrong and want to straighten things out. Once they realize the extent of this complex process that requires use of many resources, they rethink this decision and will contact an audit attorney.
Not only is the process itself lengthy and could lead to lost revenues, but mistakes and statements that raise more questions than answers can also lead to a ruling against them.
The audit has the potential to crippling overpayment assessments that diminishes presumed profits. Health care providers may also face fines, the loss of their practicing license and criminal prosecution.
The provider will have to keep the practice operating while filling out voluminous and confusing paperwork, working around staff interviews and site visits, and redirecting resource and time to comply with demands from the auditor.
Hire a Philadelphia Medicaid Audit Attorney
A thorough understanding of this taxing procedure and laws governing the process is essential to have an effective defense. Whether your audit notice arrived in the mail today or you need help with an appeal, help from a Philadelphia Medicaid audit attorney could steer the final results in your favor.
Raiser & Kenniff, PC knows that experiencing a Medicaid audit is not a one-size-fits-all process. You need someone who will analyze the facts of your case and apply the law accordingly to deliver the most effective strategy on your behalf.
Experience matters when you need someone on your side who is deeply familiar with the process. Our commitment is to use our knowledge and resources that can speed up the process while encouraging auditors to work more effectively.
Contact our offices today to learn how we can help you through the audit.
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