New Jersey Medicaid Healthcare Audit Lawyers

By Spodek Law Group | August 30, 2020

Audits are not uncommon in the healthcare industry. When you have businesses working together, everyone is trying to save themselves a bit of cash. So when an insurance provider, Medicare, or Medicaid believes that they are overpaying for a service or treatment, they may request an audit.

If you are audited by a Medicaid audit contractor, it is no reason to panic. An audit does not necessarily mean that there is a problem, but it does mean you need to be prepared to work with the auditors efficiently. To best cooperate with the audit, you will need to understand what it means and what is expected of you.

What is a Medicaid Audit?

When a patient covered under Medicaid comes in for a treatment, they will be billed a certain amount for the service and procedure. When Medicaid receives the bill for the appointment, they must determine if the amount is correct or if they believe it is too high.

If Medicaid believes that the amount is not right, they may request a contractor perform an audit. A healthcare audit does not automatically assume that the medical professional purposefully overcharged for the service or committed fraud, they simply are looking for additional information on how that number was established.

When under audit, healthcare professionals will need to provide documents, explanations, and histories of charges and bills. This can help the auditor determine if the price is correct or if they overpaid.

Who Conducts a Medicaid Audit?

There are various contractors that conduct audits, each with a different purpose. Because each contractor is looking for different information, they will work in different ways. This means that each audit a healthcare professional or medical practice undergoes, they may experience extremely different procedures.

Here are some of the main contractors who may perform a healthcare audit:

  • Recovery Audit Contractors (RACs): The RACs, or Recovery Audit Contractors comb through Medicaid payments to find if there were any overpayments and overpayments. They look for money that they may not have needed to spend and attempt to return that money to the Medicaid Trust Fund to be used on future payments. RACs are paid on a commission basis, so they receive money for each overpayment that they find.
  • Medicare Administrative Contractors (MACs): Medicare Administrative Contractors, also known as MACs, work to process claims and address billing errors. If they believe a request is not reasonable or that the procedure did not need to be done, they will deny it.
  • Zone Program Integrity Contractors (ZPICs): Where other contractors look for overpayments or errors, the Zone Program Integrity Contractors look for instances of fraud. The ZPICs look for red flags in billing processes that may mean healthcare professionals are practicing fraudulent billing practices. Other contractors may advise the ZPICs on cases or individuals that they should look into.
  • Comprehensive Error Rate Testing Program (CERTs): The Comprehensive Error Rate Testing Program looks for ways to reduce future overpayments or errors in claims. If you have a random audit, it is most likely from the CERTs. During an audit from the CERTs, they will look for potential areas that may cause errors. If they find information they feel is inaccurate or even fraudulent, they may alert another contractor to begin another investigation.

Because each of these contractors want a different outcome, it can be difficult to understand what they are looking for and how you should best comply. If you are under audit, you may want to work with a New Jersey Medicaid Healthcare Audit Lawyer.

How a New Jersey Medicaid Healthcare Audit Lawyer Can Help

When undergoing an audit, you need to provide all necessary information to the contractor auditing you. Because audits can vary so drastically and necessary information can change with each audit, you need to have a vast understanding of what the audit means.

A New Jersey Medicaid Healthcare Audit Lawyer knows the ins and outs of each kind of investigation and can guide you through it. To ensure your audit runs smoothly and efficiently, an attorney can help you determine what information is necessary.

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