Last Updated on: 19th October 2023, 01:03 pm

New Jersey Medicaid Audits Lawyers: A Helpful Guide for Healthcare Providers

Medicaid audits in New Jersey can be intimidating for healthcare providers. But with the right legal guidance, you can successfully navigate audits and avoid penalties. This article provides a helpful overview of Medicaid audits in New Jersey, potential penalties, and how experienced lawyers can assist you.

Potential Penalties and Liabilities

Depending on the circumstances, Medicaid audits can lead to:

• Recoupment of alleged overpayments
• Fines and penalties
• Payment suspensions
• Termination from Medicaid program
• Potential civil lawsuits or criminal prosecution

Even unintentional billing errors can trigger substantial penalties under applicable laws like the federal False Claims Act and New Jersey False Claims Act.

Treble damages may be imposed if overpayments resulted from “false or fraudulent” claims. This means the provider must pay back triple the amount of the overpayment. Civil penalties up to $11,000 per claim can also be imposed.

In cases of intentional fraud, criminal prosecution is possible. This can lead to imprisonment, fines, and exclusion from Medicaid. Anti-kickback violations and other offenses can also bring criminal penalties.

Why Hire a Medicaid Audits Attorney?

With so much at stake, having an experienced New Jersey Medicaid audits lawyer on your side can make a critical difference. Here are some key benefits:

• Navigate Complex Rules: Medicaid regulations are notoriously complex. An attorney well-versed in the rules can help ensure your compliance.
• Carefully Respond to Record Requests: Lawyers can help assemble responsive records and protect sensitive information through privileges and other objections. They can also negotiate the scope of audits.
• Dispute Questionable Findings: Attorneys thoroughly review audit conclusions and dispute unfounded overpayment assessments and other determinations. They identify weaknesses in auditors’ methodologies.
• Pursue Administrative Appeals: Deadlines are strict and procedural rules complex. Lawyers manage appeals to challenge adverse rulings. They also prepare persuasive arguments and evidence.
• Avoid Costly Penalties: Experienced attorneys negotiate with regulators to reduce penalties and avoid program exclusion.
• Prevent Criminal Prosecution: When fraud is alleged, lawyers protect your rights during investigations. They aim to prevent criminal charges when possible through proactive defense strategies.

Choosing the Right Medicaid Audits Attorney

Not all lawyers have the skills and experience to address Medicaid audits effectively. When selecting legal counsel, providers should:

• Look for extensive experience handling New Jersey Medicaid audits and appeals for healthcare clients.
• Verify the lawyer is knowledgeable about applicable regulations and billing rules.
• Choose someone responsive who will make your audit a priority.
• Select a respected advocate with a proven record of favorably resolving audits.
• Consider lawyers who take a collaborative approach focused on compliance.
• Expect clear guidance on your options, potential penalties, and defense strategies.
• Make sure the lawyer has strong relationships with regulators and prosecutors.
• Choose counsel with malpractice insurance for added protection.

Reputable Medicaid audits attorneys have helped many providers reduce penalties and avoid criminal prosecution. But every case is different. Be sure to ask prospective lawyers about their specific experience and credentials.

Overview of Medicaid Audit Process and Appeal Rights

To defend your interests, it helps to understand how the Medicaid audit and appeals process works in New Jersey:

1. Records Request and Audit

• DMAHS or a contractor like HMS requests records for audit.
• You have 10+ days to provide the requested records.
• Auditors review records looking for improper billing, insufficient documentation, etc.
• You may get a chance to submit additional documentation during the audit.
• Auditors issue preliminary findings detailing any alleged overpayments or other problems.

2. Informal Reconsideration

• Within 30 days, you can request informal reconsideration of the preliminary findings.
• Submit written explanations and additional documentation to show billing was proper.
• The auditors may revise or uphold the original findings.

3. Formal Appeal

• If still unsatisfied after reconsideration, you can file a formal appeal within 90 days.
• A hearing may be conducted by an Administrative Law Judge.
• This is your chance to present evidence and examine witnesses.
• The judge issues a written decision upholding or dismissing audit findings.

4. Final Agency Review

• Within 45 days, either party can seek final agency review of the judge’s decision.
• The DMAHS Commissioner reviews the record and issues a final order.
• This concludes the administrative appeals process.

5. Appellate Court Appeal

• If still unsatisfied, you can appeal the final order to the Appellate Division of New Jersey Superior Court within 45 days.
• The court reviews the administrative record but typically shows deference to the agency findings.

This summarizes the key stages in the Medicaid audit appeals process. There are strict deadlines and many complexities at each stage. Having an attorney experienced with these rules by your side can prove invaluable.

Working with Lawyers to Respond Effectively to Medicaid Audits

Healthcare attorneys serve as trusted advisors and advocates throughout the Medicaid audit process. Here are some of the ways they can help:

Carefully Review Audit Notices

Lawyers will scrutinize any audit notices and record requests you receive. They will look for defects that could make the audit invalid or limited in scope. The lawyer can also discuss strategies to get clarification from auditors.

Assemble Responsive Records

Experienced audits attorneys know what types of documentation auditors want to see. They will work with you to gather relevant medical and billing records. The lawyer will withhold any privileged materials. They may also negotiate with auditors to limit the scope of records requests.

Evaluate Billing and Documentation

Your lawyer will thoroughly review the records before production to identify any compliance problems or gaps in documentation. The attorney can offer remedial steps and help get your billing practices in order before the audit concludes.

Dispute Unfounded Allegations

When you receive preliminary findings, your lawyer will scrutinize them for unfounded assertions. They will point out flaws in auditors’ reasoning and evidence. The attorney submits written disputes backed by documentation and legal arguments.

Handle Audit Appeals

If the auditors impose penalties or recoupment, your attorney will advise on the merits of appeals. The lawyer handles each stage of the appeals process, meeting deadlines, gathering evidence, and forcefully presenting your arguments.

Negotiate Favorable Resolutions

In many cases, attorneys can negotiate settlements with regulators to reduce penalties and overpayment demands. They work cooperatively with the government when possible to achieve fair outcomes.

Defend Against Criminal Prosecution

If allegations escalate to fraud investigations, your attorney protects your rights and works to prevent criminal charges. Experienced lawyers engage prosecutors to dissuade them from pursuing indictments.

Coordinate Defense Strategy

For large providers, Medicaid audits often lead to lawsuits and multi-agency investigations. Lawyers coordinate across these proceedings to present consistent defenses. They bring efficiency and cohesion to the defense strategy.

Having an attorney guide you through the audit and appeal process can vastly improve your chances of a favorable outcome. Their expertise allows you to focus on serving patients rather than getting lost in regulatory complexities.