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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.
Appeals are governed by state law. Therefore, if a health care provider wants to appeal an audit determination, they must do so through the state’s appeal process.
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.