Medicaid Audits & Appeals

In recent years, the federal government has stepped up its efforts to crack down on healthcare fraud. Medicaid is no exception, and several agencies and sub-contractors regulate potential fraud and abuse. Hospitals, healthcare providers, and related industries need to be careful due to the many groups involved in Medicaid audits and policy enforcement. 

The legal complexities can quickly get out of hand without oversight and diligence. Thankfully, our lawyers can guide you through audits and appeals and streamline the process. Norman Spencer Law Group is experienced with various healthcare cases, including Medicaid audits. 

There are many types of Medicaid audits, each covering its areas or with different agencies to run them. However, the Centers for Medicare and Medicaid Services (CMS) is responsible for enforcing Medicaid regulations. Depending on what your organization is being questioned for, a different audit might apply. The most common types of Medicaid audits you can run into are: 

RAC: Recovery Audit Contractors are private entities contracted by the Centers for Medicare and Medicaid Services (CMS), which look for Medicaid overpayments and underpayments. RACs review submitted healthcare claims, and they have incentives to look for overpayments since they get a portion of the payments they identify.

CERT: Comprehensive Error Rate Testing is used to see if a recipient properly pays out claims. These audits mainly focus on logistics, especially coding procedures, and these are not targeting any particular physician but initiate from coding errors. 

UPIC: Unified Program Integrity Contractors audits investigate healthcare providers in order to stop alleged Medicaid fraud, waste, or abuse. These audits are triggered by patient complaints, billing errors, coding errors, or questionable administrative action.

TPE: Targeted Probe and Educate reviews to focus on payors with high claim error rates or billing practices that vary from peer institutions. These audits have multiple rounds of reviews, usually culminating in a training or education session with the provider.

SMRC: Supplemental Medical Review Contractors conduct Medicaid audits to ensure that claims follow proper billing practices, coding procedures, and appropriate coverage practices. Their goal is to lower improper payment rates and increase efficiency for payors.

QIO: Quality Improvement Organizations are groups of health quality experts, clinicians, and consumers who work together to improve the quality of Medicare and Medicaid for patients. These audits look at provider data alongside patient reports to determine how to best fix an issue that a provider may have. 

Despite the different audits that can come up due to Medicaid regulations, the first step is determining what type of audit you are dealing with and why it has come up. Notify your employees or superiors at once so your organization is not caught unaware. Keep all relevant documents on hand, and do not forget to save copies of all communication with the government agency initiating the audit. You can also pursue an appeals process, though there are some considerations.

While many Medicaid and Medicare appeals end up successful, it is not always the best option to take. Since the process is a lengthy, multi-stage ordeal, it can be inefficient for every audit you encounter. An appeal may not be needed if the audit is over a minor issue that is easily correctable or does not result in significant monetary penalties. However, if the audit reveals errors leading to substantial financial loss or can set a precedent for future audits, an appeal may be the correct move.

No matter what kind of audit or appeals battle you may be facing, the real first step is to have a healthcare defense attorney on hand. Since an audit can blindside you, it is better to have connections with lawyers experienced in healthcare law before you are given an audit notice. Every step of the audit and appeals process becomes that much less problematic.

Attorneys with Medicaid audit experience can make the entire process smooth. They can help gather paperwork and correspondence and file any appeals. A good team can ensure your employees are up to speed and mitigate any damage during an ongoing audit. If an audit leads to training programs or educational sessions, an attorney can also guide you through those. 

At Norman Spencer Law Group, we have a team of attorneys who have healthcare defense experience that you can rely on, and Medicaid audits are no exception to that. We can help you plan an audit defense, an appeal and will even defend you in court if necessary. Call us for a free consultation. We can talk over the phone, email, ZOOM, or even meet you in person to discuss your case.