Last Updated on: 2nd August 2023, 01:04 am

Obstacles Facing Healthcare Audit Providers

Audits for health care providers face different obstacles, depending on the type of health care they are providing as well as where the audit came from. Overpayment allegations can be made by several different Medicaid and Medicare audit contracts including Recovery Audit Contractors (RACs)and Medicaid Integrity Contractors (MICs).

Different Audit Processes

These contractors have the objective of finding overpayment and fraudulent behavior by these health care providers and they each have a different way to audit an individual process. Because of this, providers can’t assume that because they have had an audit in the past that the approaching a new audit will be the correct way to proceed. Each contractor has their own audit process and they can also be different in what financial incentives they need to push for as their maximum recovery amounts.

Highly Experienced Attorneys

Our attorneys are highly experienced and proficient in handling all forms of audits. Our attorneys have a tried and true strategic approached that we developed to each different type of audit based on vast knowledge and experience. Based on the unique details of your case, we can develop a plan of action to most effectively defend against the allegations you face.

Medicaid Audits

As a part of the effort to find and prevent Medicaid fraud, the Medicaid Integrity Program (MIP) was created and their audits are designed to detect fraud and errors and ultimately recoup any overpayments. MIP is executed by several Medicaid Integrity Contractors (MICs) who conduct the reviews and audits that help to identify and recoup any improper payments. These MIC’s act with the Medicaid agency in each state and provide oversight and technical aid. The requirements of the MIP allow CMS to hire MICs to review the claims and conduct the audits as well as to educate providers about the proper Medicaid claims compliance.

Types of MICs

The MICs are split into three different types depending on what their main task is:

Review MIC’s
Education MIC’s
Audit MIC’s
The review MIC’s identify providers that need to be audited and any potential reviewing claims that were submitted at least five years back.

Audit Process

The audit MIC then takes over the case and informs the provider with a notice of the audit and then requests records. In the early part of the audit, the provider will have an initial meeting with the audit MIC and it can then be determined if it is a field audit or a desk audit. In the early stages of the audit, the provider will also have an entrance conference with the audit MIC.

After the audit is finished, the audit MIC will submit a draft of the audit to the state Medicaid agency that will then review it and makes comments on whether the Medicaid policies in the state were followed correctly. After that, the report is forwarded to the provider who has 30 days to submit any additional comments or information within 30 days.

Compensation Differences

MIC’s are not compensated like RAC’s so they are not paid on a contingency basis and don’t even collect the overpayments. When the overpayments have been identified, the state will take over collecting the amount due from the providers and then the federal government gets its share directly from the state. State law governs any of the appeals from an MIC audit determination. Medicaid fraud, if found, can be criminally prosecuted either from the result of an audit or an investigation by the state or federal government.

Complex Laws and Regulations

Audits and appeals in Medicaid cases can involve many complex interactions of the state and federal law. Our attorneys are high experience in effectively negotiating the many complex laws to receive a successful outcome. Medicaid overpayment and fraud allegations can include criminal prosecution, fines, civil suits and also exclusion from the Medicare and Medicaid program.

Medicare Audits

Audits for Medicare focus on payment for service that were actually performed by the health care provider and that all service met the Medicare coverage conditions as well as were medically necessary. Genuine fraud does not need to be committed for an audit to occur. Mistakes in complicated paperwork or misinterpretation of contracts provisions as well as conflicting opinions on what medically necessary means can cause an audit to occur.

Mistakes and Misinterpretations

Health care providers that try to handle audits on their own often think that they didn’t do anything wrong so it should be easy to fix without help find that the audit process is very complicated. It’s important to contact an attorney to walk you through the many steps of an audit so that there aren’t any mistakes that cause you to lose resources and money while the audit process continues on. Our attorneys also know that many of the CMS contractors are paid based on how much money they recover so they have less interest in negotiating and will want to recover as much of the funds as possible.

Legal Assistance at Any Stage

Our attorneys can offer assistance to a health care provider at any step of an audit. Whether you were just notified of an audit or you are in the appeal stage, our attorneys can assess your case and come up with an individualized approach. Our highly qualified attorneys have extensive experience audits and appeals to help you get the most successful outcome possible.

Increased Scrutiny of Healthcare Providers

As today’s healthcare world becomes even more complex due to increased regulations, it’s clear that more and more healthcare providers are under tremendous scrutiny when it comes to Medicare and Medicaid payments. Because of this, the Centers for Medicare and Medicaid Services, or CMS, has added a number of additional programs designed to take a closer look at submitted claims, which has naturally resulted in more and more audits being conducted. For healthcare providers who find themselves on the receiving end of a Medicare or Medicaid audit, there are several key points to keep in mind.

Notices of Overpayment

For any healthcare provider, the one thing they do not want to receive is a notice of overpayment from CMS. However, as health care reform and other increased regulations have added an extra layer to the already strained healthcare system, these notices are becoming more commonplace among the healthcare community. As a result, the demand for the services of attorneys skilled in Medicare and Medicaid auditing has grown substantially within the past decade. Even though a healthcare provider is not required to have legal representation during an audit, going without it could prove very costly. Due to the appeals process related to an audit being very confusing and time-consuming to those who are unfamiliar with it, it’s imperative to have an attorney who has experience in this area.

Recovery Audit Contractors

For healthcare providers who find themselves being contacted by a recovery audit contractor, also known as an RAC, the situation can become difficult in a hurry. In most cases, an RAC is compensated on a contingency-fee basis, which can lead to an increased number of audits due to supposed overpayments. In fact, research has shown an RAC will almost always uncover far more overpayments than underpayments. Along with scrutinizing standard Medicare claims, an RAC also examines Medicare Advantage plans, Medicare Prescription Drug plans, and Medicaid claims.

Comprehensive Error Rate Testing

In order to determine why overpayments happen, the CMS has developed a testing program known as the Comprehensive Error Rate Testing program. Known as CERT, it aims to discover the major reasons for overpayment and how to avoid future errors. While CERT works on more than 120,000 claims each year, healthcare providers who find themselves being audited are subject to increased scrutiny. For providers who find themselves receiving notifications on a regular basis, chances are they will need the services of an experienced Medicare and Medicaid audit attorney in order to rectify the situation.

Medicare Appeals

During the course of their careers, most healthcare providers at some point find themselves appealing a decision made by the CMS. When this is the case, the services of a knowledgeable Medicare audit attorney will be needed in order to navigate the complexities of the case. Whether it’s in the form of a demand letter or an indication given on an Explanation of Benefits, or EOB, these appeals can become extremely complex.

Administrative Law Judge Hearings

When this happens, a variety of options are available. One of the most common is having a hearing before an Administrative Law judge, which can be conducted in person, over the telephone, or even through videoconferencing. These hearings, due to their importance, almost always require a provider to have proper legal representation. By doing so, they can be assured an attorney has been able to examine all available evidence prior to the hearing.

Appeals Process Variations

Along with these parts of the appeals process, there are several other variations providers may face from time to time. One of these involves Medicaid Integrity Contractors, which were created in 2005 to conduct reviews and audits. Due to the Deficit Reduction Act of 2005, the federal government has since greatly expanded its focus on Medicaid payments and the possible fraud associated with them. While this has led to some healthcare providers reducing or eliminating their Medicaid patient caseload, it has also led to an increase in the number of cases being examined for potential fraud.

Legal Representation is Imperative

For those who find themselves facing a Medicare or Medicaid audit, having the services of an attorney who is experienced in these legal matters is imperative. Whether it’s a hearing with an Administrative Law judge or a meeting with a Recovery Audit Contractor, understanding this process is vital for success.