The federal government has several tools to root out fraud in the healthcare industry, and a big one is the ability to audit a healthcare provider. This happens through federal contractors, state agencies, or even private auditors, and Medicaid is one of the most significant areas that the government focuses on. Finding yourself on the other end of a Medicaid audit can be intimidating, but it is not the end. Several procedures can let you get through such an audit with minimal damage, and having a lawyer who is well-versed in these matters can make it even easier. If you are dealing with a Medicaid audit, the Norman Spencer Law Group has you covered.
Steps in the Appeal Process
While there are many different types of audits that you might face, there are five steps to the appeals process.
Redetermination: This is the first step of appealing a Medicaid audit. Requesting a redetermination must be done within 120 days of receiving the initial determination from the Centers for Medicare and Medicaid Services. Remember that the auditor can start recouping alleged overpayments while an appeal is in the process unless the request is filed within 30 days of the initial determination. Filing a redetermination early is always preferable.
Reconsideration: This is the second step of an appeal and is handled by a Qualified Independent Contractor (QIC). A request for reconsideration is filed within 180 days of receiving the CMS redetermination decision, and contractors can begin recoupments within 60 days of the notice. All evidence of an appeal is submitted at this stage since no new evidence will be allowed in the later stages of the appeal.
Administrative Law Judge: A hearing before an Administrative Law Judge is the third step in the appeals process. The request for a hearing must be filed within 60 days of receiving the reconsideration decision. Unlike the first two steps, a hearing request must also meet a certain amount of controversy, which changes annually. Multiple claims can be grouped to meet this amount.
Medicare Appeals Council: A Medicare Appeals Council review is the fourth step to appealing an audit. A request for this review must be filed with the court within 60 days of receiving the Administrative Law Judge hearing receipt. It must also meet controversial requirements that change annually. The provider has to explain why it disagrees with the Administrative Law Judge. This step does not involve a hearing, though you can request an oral argument.
Federal District Court: The final step of the appeals process is a review in a Federal District Court. Much like the previous step, this request has to be filed within 60 days of receiving the Medicare Appeals Council decision. This request also requires a certain amount of controversy, which changes annually.
These steps are the general structure that a Medicaid appeals process follows, but every state has its regulations and administrative procedures. In many states, there is the option of opting for an informal resolution or a settlement.
Attorneys and Medicaid Audit Appeals
Appealing a Medicaid audit can be lengthy, with numerous federal and state regulations. Having an experienced attorney from the moment an audit notice is received can make a difference. A Medicaid appeals attorney can help gather all the documents needed for all five steps of the appeals process. They can help you stay on top of the deadlines for all of the different steps when requesting further appeals. Also, they can prepare you for a hearing, plan your defense, and even help you reach an informal settlement if the appeal gets that far. If the case continues, they can defend you in Federal District Court.
At Norman Spencer Law Group, we have a team of attorneys that is very familiar with Medicaid audits and appeals. We know how demanding a Medicaid audit can be. If you have received an audit notice, do not wait to contact us. We can set up a free consultation via phone, ZOOM, email, or in person.