By Spodek Law Group | August 30, 2020

Medicaid billing and reimbursement is governed by thousands of regulations meant to make sure that healthcare providers such as hospitals, physicians and even nursing facilities do not commit Medicaid fraud such overpayments. Perhaps because of this high number of regulatory requirements, thousands of medical practices and facilities get audited each year by Medicaid for suspected Medicaid fraud. If the audit proves that fraud or series of frauds were committed, consequences can be quite grave. In New Jersey, such Medicaid frauds are punishable by fines as high as $10,000 and up to 3 years of jail time. It is, therefore, not for no reason that getting a notification that your practice is going to be audited for suspected Medicaid fraud is one of the scariest news a doctor can ever receive. Usually, it is very hard to satisfactorily resolve cases of alleged Medicaid fraud without the help of lawyer with considerable experience in issues of Medicaid audits and fraud. Having an experienced NJ medicaid audit lawyer guide you during the audit process can have a huge difference on the outcome of the case. Here is a look at some of the things a Medicaid audit lawyer can do for you to help you have a successful audit.

Determining reason for the audit

The notification letter for audit usually contains reason(s) for carrying out the audit on your practice and the scope of that audit. Most of these notification letters are usually straightforward. However, there are others that may be worded in a manner that does not clearly bring out the reason or reasons for the audit. An audit lawyer will help in clarifying these reasons and explain to you the specific regulatory requirement you are alleged to have ignored. This is important as it helps you make the necessary changes to avoid a similar audit in future.

Determining the kind of documents to present to the auditors

Medicaid auditors usually request specific documents for use in the audit process. However, sometimes doctors are often at a loss on whether to present the exact requested documents or give them a few additional ones that might support their case. Depending on the situation, presenting the auditors with extra documents might or might not be of help. A Medicaid lawyer will carefully assess your situation and determine if presenting such additional documents is necessary. If there such need, the lawyers will help you in choosing the specific documents that will best explain your medical decisions. Preparing the documents with the help of an audit lawyer will also help you avoid taking actions that make you appear guilty such as making changes to the documents.

Filling in the questionnaires

When Medicaid auditors come to audit your practice they seek to identify specific suspected violations of regulatory requirements that you may have committed. Usually, this involves checking out for any billing errors. Apart from asking for documents, they also require you to fill in questionnaires for use in the audit process. Having a NJ Medicaid audit lawyer will help you fill in the questionnaires in an accurate and appropriate manner that does not raise any further suspicions.

Finding coding consultants

During the audit process, you may need coding consultants and other experienced professionals to help you go through the experience successfully. With their experience and knowledge of experts in the field, Medicaid audit lawyers will help in finding for you the best coding consultants. Using your Medicaid audit lawyers to find coding consultants for you also has a major legal advantage. If you decide to hire your own consultants, auditors can have access to their findings and use them as evidence against you. However, if it is your lawyer who hired the consultants, there are ways in which the auditors can be denied access to their findings. This is very important as findings from coding consultants can make a huge difference in your case.

Planning your defense

Medicaid audit lawyers with considerable experience usually know all the tricks used by auditors in cases involving doctors suspected of Medicaid fraud. Through their experience, they can foresee some of the arguments the auditors are likely to use in the case and use those likely arguments to plan your defense. This helps you in getting the best outcome possible.

Determining the best cause of action if you are found guilty

Hiring a Medicaid audit lawyer increases your chances of having a successful audit that leaves your practice intact. However, sometimes auditors find even honest doctors to have committed Medicaid fraud. If this happens, your lawyer will carefully analyze all the options available and choose one that will give you the best outcome for your situation. For example, if the Medicaid audit lawyer thinks that there are grounds for appeal, they may decide to take that option. Sometimes, they may help in reducing your fine and even avoid criminal prosecution.

Appealing a negative audit decision

A normal audit is usually stressful, time consuming and very stressful. An appeal is even more stressful and complicated. It involves a lot of research and paperwork with very tight deadlines to meet. The extensive research and documentation needed can take up so much of your time that it becomes difficult to effectively attend to your patients. Then there are also numerous procedural and legal arguments that can only be made effectively by a lawyer experienced in cases involving Medicaid fraud. Hiring an experienced audit lawyer will, therefore, not only make the whole process a lot easier but also improve your chances of having a successful appeal that allows you to continue enjoying all your medical privileges. Even if you decide to handle the appeal on your own, it is still important to seek the help of a Medicaid audit lawyer. They will help you in drafting templates and briefs for use in the appeal process.

Avoiding future audits

Whether the auditors find you to have committed fraud or not, Medicaid audits are still frightful experiences. The fines, lost time and high cost involved in having one is usually very stressful to many doctors. After experiencing one, no doctor would want to have another one. Hiring a Medicaid audit lawyer will help you achieve just that. They will advise you on some of the issues that may result in future legal problems and the changes you need to make to avoid future audits and other legal problems. In addition, the coding consultants hired by your audit lawyer will let you know the coding patterns that resulted in the audit being done and the kind of changes you need to make to your coding and charting methods to avoid a repeat audit.

Running a modern medical practice is more complicated than it has ever been. There are thousands of laws and regulations that you have to comply with. Whether it is out of ignorance or accident, it is very easy to raise suspicions of Medicaid agents and have your practice audited for suspected fraud or violations of one or more of these regulations. As shown above, if you receive a notification to audit your practice the first step you should take is to hire an experienced Medicaid audit lawyer. That will go a long way in ensuring that you get the best possible outcome for your practice.

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