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Medicaid audits have become a headache for healthcare professionals across the United States. With cases of medical insurance fraud increasing by the day, the government has upped the ante on cracking down on perpetrators. The downside of this is that even institutions and professionals who have nothing to hide fall under the same scrutiny. You may end up dealing with a Medicaid fraud case without knowing how you got there.
Medicaid audits can be launched against physicians, nurses, mental health workers, nursing homes, hospitals, home health agencies, and pharmacies among others. The Center for Medicare and Medicaid services is responsible for the various programs that conduct audits. Understanding the different components of these types of audits is essential for all healthcare providers.
Understanding Medicaid Audits
A Medicaid audit is triggered by errors in the billing system or coding patterns. If something raises suspicion, then an inquiry will follow. At this point, a healthcare provider is required to submit documents and data for investigation. It is advisable to be as cooperative as possible during this stage. Note that just because a coding system raised some red flags does not automatically equal to fraud. After looking at the information, Medicaid can then decide on an audit. The auditors can then make a choice to do an investigation or not, which depends on what they find.
The government set up the Medicaid Integrity Program to detect and punish Medicaid fraudsters. Medicaid Integrity Contractors work with state agencies to recover overpayments from healthcare providers. Besides providing oversight, MICs also offer technical support to local Medicaid agencies during audits. MICs come in three kinds – review, education, and audits. An MIC can investigate a claim as old as five years, which is why these audits can be tricky. You may not even have an idea what you are guilty of when being put under investigation.
Sources of Audits
Audit processes vary broadly depending on who is handling them. Recovery audit contractors are some of the auditors that check out claims of Medicaid overpayments. One fundamental to keep in mind when dealing with RACs is that they get paid on a contingency basis, meaning the more cases of overpayments they can find, the higher the income. For this reason, healthcare professionals may find themselves dealing with RACs more often than not.
Other auditors include Comprehensive Error Rate Testing programs (CERTs), Medicare Sone Program Integrity Contractors (ZPICs), and Medicaid Integrity Contractors (MICs), as well as Quality Improvement Organizations (QIOs).
A healthcare provider may come across more than one of these contractors. However, just because you have a experience with one does not mean that it will be the same with the next one. The protocols are different, and so are the approaches. One contractor may fail to find overpayments in your system, but another one does. It is why you can’t afford not to have a legal expertise in Medicaid fraud cases.
Medicaid fraud case lead to a criminal prosecution; and consequently, severe penalties. If an audit turns up proof of overpayments, then a healthcare provider may be liable for enormous fines and penalties. Also, an institution or professional may lose their license as a result of an investigation, regardless of who or how it started.
Medicaid audit lawyers have worked on such cases and grasped what is at stake. An attorney will offer guidance during an audit process to ensure you don’t end up in more trouble than you are in. It is helpful to have a specialized lawyer, particularly when dealing with bogus claims of overpayments.
It is possible to appeal the results of a Medicaid audit if there is substantial cause. However, such appeals are not without their complexities. Whether it’s appearing at a hearing or drafting a letter of demand to the CMS, having legal representation will simplify a lot of aspects. Appeals also vary in processes, depending on their nature.
The difficulties that come with certain billing systems are the culprits in a majority of Medicaid fraud cases. With the increased vigilance in the system, it is hard for a healthcare provider to get away even with simple miscalculations. Medicaid audit lawyers can serve various purposes in such circumstances. For one, they can explain the reason for an audit. An attorney will also guide you when submitting documents to ease the process. Medicaid audit lawyers have experience dealing with different contractors and that knowledge will serve you well.