It’s just a normal day in the office. You are running late, the waiting room is packed, and then your office manager appears with a panicked look on her face. Medicaid has notified you that they are going to audit your practice.

Most doctors think that this scenario will never happen to them, but it is surprisingly common. Thousands of doctors and practices are audited every year by Medicaid; even more are audited by other health insurance entities such as Medicare and private insurance companies. While this is a frightening situation that can have grave consequences, an experienced lawyer can help you get through the experience with your practice intact.

What Happens in a Medicaid Audit?

In a Medicaid audit, Medicaid has decided that they suspect you are fraudulently or otherwise improperly billing them. Thus, they decide to request documentation behind the coding that was submitted. A Medicaid audit usually happens when something in your billing has been flagged as potentially fraudulent. This may be a particular case or a pattern of coding. There are several ways to be flagged for an audit; many of these are not fraud.

In most cases, the auditor will ask that you submit copies of certain records and documents. They will give you a list, usually in the first letter announcing the audit. After you have submitted all requested documents, the auditor will review them and decide whether further investigation is needed.

At the end of the investigation, you may receive a clearance letter, which means they are satisfied that no fraud or inaccurate billing occurred. On the other hand, you may be instead subject to fines, repayment of overbilling, loss of your ability to bill Medicaid for services, or even jail time. Most doctors come out of a Medicaid audit unscathed if they get the help of a qualified attorney.

Why Do Doctors Get Audited?

Medicaid fraud is a growing problem in the United States, adding billions of dollars to state medical expenditures every year. Medicaid has identified certain billing practices that, while not always fraudulent, can indicate that fraud may be occurring. If you commit some of these red flags, even in the honest and responsible practice of medicine, you will be ‘red flagged’ for an audit.

While few doctors are committing outright fraud, many break rules in small ways. For example, they may bill for procedures performed by nurses that require on site supervision even when they are not in clinic or office. These small issues can be exposed in an audit and have huge consequences.

What Can I Do If I Get Audited by Medicaid?

The first step when you are audited by Medicaid is to contact a lawyer who is experienced in this area. Then, you should thoroughly read the letter announcing the audit. In many cases, this letter will tell you why you are being audited and give an idea as to the scope of the audit.

The letter will ask for certain documents and records. You should submit these as soon as possible. It is important to keep copies of all communications that you have with the Medicaid auditor and anyone else involved in the audit. In some cases, you may want to submit more than the audit requests, especially if these documents will support your decisions and coding.

If your office is behind on paperwork, now is the time to catch up. Make sure your filing bin is empty and everything is up to date. However, do not make any changes to existing records. Many doctors are attempted to expand their charting on the cases being reviewed to explain their decision-making, but this rarely ends well. Even if you use correct dating and are adding only correct information, changing a medical record in an audit will often make you look guilty.

How a Medicaid Audit Lawyer Can Help

There are several ways that a Medicaid audit lawyer can help. First, they can often determine the reason for the audit if this has not been made clear. This will help you to avoid penalties while allowing you to make different choices in the future. Second, a lawyer can help you decide what documents will best support your case. It is important to submit the records that Medicaid requests, but whether to send extra will depend on your situation. In some cases, the best decision is to send only what is specifically asked for; in others, there may be additional documentation that will support your case.

Another reason to hire a lawyer is that they can help you to find the best coding consultants and other professionals to support you. If you hire your own consultants, their findings will be evidence that Medicaid can access and use against you. If your lawyer hires the consultant, there are ways that the information can be legally withheld from auditors. The power to decide what evidence to submit can make a huge difference in the outcome of your audit.

Last, an experienced Medicaid audit lawyer knows the tricks that auditors use. They can foresee what arguments will be used and actively plan a defense. While most physicians have never experienced a Medicaid audit before, specialist lawyers have been through hundreds. In law as in medicine, experience and professional judgment matter.

What If I Am Found Guilty of Wrongdoing in a Medicaid Audit?

A Medicaid audit lawyer can increase your chances of successfully navigating an audit. However, many honest physicians are still found to have committed wrongdoing. If this happens to you, your lawyer can walk you through your options and help you select the one that is best for your situation. In many cases, the audit can be appealed. Sometimes, your lawyer can help you to avoid fines and criminal prosecution so that you only repay the disputed charges.

A Medicaid audit requires a great deal of paperwork and research. Appealing an audit is even more complicated, with tight deadlines. Hiring a qualified lawyer will not just give you a better chance of keeping all medical privileges, but make the entire process easier on you as well. You can continue to see patients and live your life while your attorney handles the research, documentation, and footwork needed to get the final clearance letter ending the audit.

Avoiding Audits

An audit that does not lead to fines or other sanctions is still a very time-consuming, expensive, and stressful experience. Any physician who has been through one will want to avoid dealing with this in the future. A Medicaid audit lawyer helps you to come out of an audit without sanctions, but they can also help you to avoid having another. The hired coding consultant will tell you what coding patterns caused the audit in the first place so you can change your approach in the future.

In addition, the coding consultant can help you to modify your charting and coding so you are always completely compliant in the case of a future audit. Illegible charting and incomplete histories or documentation, for example, are simply not best practice. The lawyer can also advise you about issues that can cause legal problems in the future so you can make meaningful change before there is an audit or lawsuit.

Modern medicine is more complicated than ever. There are thousands of ways to accidentally run awry of Medicaid regulations, and just as many ways to raise suspicions. A Medicaid audit lawyer can help you to make the little changes that will keep your office compliant and audit-free in the future.

It is normal to be concerned when you find out that your practice is undergoing a Medicaid audit. However, with the help of an experienced Medicaid audit lawyer, you will likely be cleared of all suspicion and be able to continue your medical practice with no negative ramifications. If you have received notification of an audit or are concerned about how to avoid one, contact a lawyer today.