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Medicaid services make it possible for millions of residents in the U.S. to receive healthcare. The program caters to a wide range of patient needs from general to specific care. Cases of overpayments and incorrect billing of Medicaid services have led the government to strengthen its stance on regulations.
Measures have been established to guarantee that these cases are handled efficiently. The Medicaid Integrity Program was put in place to deal with cases of abuse, fraud, and the waste of funds. Part of the provisions of the MIP is the use of Centers for Medicare and Medicaid Services to carry out investigations.
The Social Security Act, Section 1936 gives the CMS mandate to hire auditors for the purpose of investigating claims of overpayment. For this reason, the MIP procures Medicaid Integrity Contractors to conduct audits. These contractors have a duty to review the actions of a healthcare provider in addition to providing education on issues of integrity. MICs also have the right to work with Medicaid centers in San Antonio.
Besides MICs, healthcare providers have to deal with other types of contractors. Recovery Audit Contractors do just that, recover overpayments. They are paid according to the number of cases they uncover. It means that the simplest claim against a healthcare provider will come into question. After all; the more they uncover, the better the pay. Also, RACs are private contractors; and so, they may be looking to build a name at your expense.
The methods contractors use to carry out their reviews vary on a very wide scale. Health care providers can get rail-roaded when dealing with Medicaid audit contractors. Regardless of the contractor you are dealing with; the bottom-line is the same – find proof of overpayments and financial misconduct. Nonetheless, auditors will utilize different formulas for calculating overpayments, if there are any. The expertise of a Medicaid audit lawyer can swing things in your favor. Understandably, it is difficult for a practitioner or administrator to know about every single Medicaid audit regulation in San Antonio. An experienced attorney has the resources to learn every single rule. When feeling confused about the justification for an audit, a lawyer can explain it.
The punishment for Medicaid fraud is severe. If there is proof of overpayment, then the state collects the calculated amount from the healthcare provider. Depending on the size of these amounts, an institution may have to pay millions, which can easily ruin your practice.
Criminal prosecution is another possible outcome of a Medicaid audit. A criminal conviction can damage your reputation, especially due to the revocation of your practicing license. Monetary losses may be hard but not impossible to recoup. Your credibility is something else. Having a lawyer from the beginning of an audit can prevent things from getting to that point.
It may only take some negotiation to turn a license revocation to a suspension or a prison sentence to probation. A lawyer who understands Medicaid audit protocols can work out a favorable deal.
A Medicaid audit starts with a claim and is followed by the review of documents of a healthcare provider’s operations. When the Medicaid Center in San Antonio asks for certain information, you have to provide it. One error in judgment that some entities make is to give unrestricted access to data. It is possible to self-implicate with such a move. You may provide ammunition for a case that wasn’t even being investigated. An attorney would be useful in this situation by guiding you on the documentation to provide.
A healthcare provider can end up being excluded from Medicare and Medicaid programs if found guilty. Such a penalty may cripple the operations of a healthcare provider considerably. A hospital or clinic whose clientele is largely Medicaid enrollees would lose most of their business. An attorney can help mitigate such consequences.
Medicaid Audit Appeals
A Medicaid overpayment claim can be the result of whistleblowing, a patient complaint or a reflag in the billing system. For this reason, an audit can be based on false information or a mistake. In such an instance, you may opt to appeal the results of an audit. Medicaid appeals are, however, very complex and require a subtle approach. Without a proper grasp on how the system runs, your appeal attempts may be futile. A Medicaid audit attorney has the expertise to handle an appeal.