Healthcare providers may face different types of audits, depending on the kind of healthcare they provide, as well as the source of the audit. Allegations of overpayment may be made by various Medicare and Medicaid audit contractors, including Recovery Audit Contractors (RACs), Medicare Sone Program Integrity Contractors (ZPICs), Comprehensive Error Rate Testing programs (CERTs), and Quality Improvement Organizations (QIOs), as well as Medicaid Integrity Contractors (MICs). Audits for overpayment by private payors are initiated by commercial insurance companies and the contractors they may choose.

While all of these contractors have the aim of detecting overpayment and fraudulent conduct by healthcare providers, each of them has a different approach to auditing and an individual process. For this reason, providers should not assume that just because they have dealt with one type of audit in the past, the same approach can be successfully taken with another type of audit. Each contractor has developed its own audit process. Contractors also differ in terms of the financial incentive they have to push for maximum recovery amounts. Those that are compensated based on a percentage of the amount they recover will, unsurprisingly, be less amenable to negotiation than those retained on a flat fee basis.

Our attorneys are experienced and highly proficient in dealing with all the different types of audits. We have developed tried and true strategic approaches to each kind of audit, based on deep knowledge and extensive experience. Based on the individual facts of your case, we will formulate a plan of action for the most effective defense against the allegations you are facing.

Medicaid Audits

The Medicaid Integrity Program (MIP) was established as part of the escalating effort to detect, prevent, and penalize Medicaid fraud. MIP audits are aimed at detecting fraud or error and recouping overpayments.

MIP is implemented through multiple Medicaid Integrity Contractors (MICs), which conduct reviews and audits in order to identify and recoup improper payments. MICs work with each state’s Medicaid agency, providing oversight as well as technical aid. Under the provisions of the MIP, CMS hires MICs to review claims and conduct audits, and also to provide education for providers about proper Medicaid claims submission compliance.

MICs are divided into three types, according to their main tasks: review MICs, education MICs, and audit MICs. The review MIC identifies providers to be audited, potentially reviewing claims submitted as far as five years back.

The audit is then undertaken by the audit MIC, which will write to the provider with a notification of the audit and a request for records. In the early stages of the audit, the provider will also have an entrance conference with the audit MIC. Depending on the specific situation, an audit can be a desk audit or a field audit, and an audit MIC can as little or as many records as it deems necessary.

After concluding the audit, the audit MIC submits a draft audit report to the state Medicaid agency for review and comment on whether the state’s Medicaid policies were correctly followed. The report is then forwarded to the provider for comment and additional information, which the provider has 30 days to submit.

Unlike Medicare RACs, MICs are not compensated on a contingency basis and are not even in charge of recovering overpayments. When overpayments are identified, the state steps in to collect these amounts from the providers, while the federal government collects its share of the recouped overpayment directly from the state. Appeals from MIC audit determinations are governed by state law and the state’s appeals process.

Medicaid fraud can also be criminally persecuted, whether as the result of an audit or of an independent investigation by federal or state authorities.

Medicaid audits and appeals often involve complex interactions of state, federal, and administrative law. Our attorneys are experienced in successfully negotiating the various complex laws in order to obtain optimal results for our clients. As with Medicare, allegations of Medicaid overpayment and fraud can result in far-reaching consequences including criminal prosecution, civil suits, fines, and exclusions from Medicaid and Medicare programs. With your career, livelihood, and even freedom on the line, the best course of action when confronted with a Medicaid audit is to consult a qualified attorney immediately.

Private Payor Audits

Providers whose services are covered by commercial insurers may find themselves facing third-party payor audits. The process for such an audit will depend on the specific insurer involved. Typically, providers learn that they are being audited upon receiving an initial notice requesting the submission of medical records in reference to a claim, or notification of an impending on-site audit by the payor. During on-site audits, auditors may examine and review medical records, inspect facilities, and interview staff and beneficiaries.

Our firm represents providers facing audits, claim denials, and overpayment demands by commercial insurers. We have the experience and knowledge necessary to mount an effective defense and pursue a favorable outcome in your case.

Healthcare providers today are aware of the ever-increasing oversight from Centers for Medicare/Medicaid Services (CMS) and their contractors and payors. With the current addition of new Medicare and Medicaid programs administered through various contractors, there has been a proportionate rise in vigilance to eliminate overpayments and inappropriate claims. In this climate, any bill submitted by a provider can potentially trigger an audit.

Medicare audits focus on ensuring that providers are only paid for services that were actually performed and that all services are not just medically necessary but also meet the coverage requirements for Medicare. While most discussions of audits and recovery efforts focus on preventing fraud, it is important for providers to understand that actual fraud does not need to take place in order for an audit to be triggered. Mistakes in ever more complicated paperwork, misinterpretation of a contract provision, or simply a differing opinion as to what constitutes medical necessity can all result in being audited.

There are many providers who start out trying to handle an audit on their own, reasoning that they know they have done nothing wrong and can just straighten everything out themselves. Later, they come to realize the extent to which the audit process is complicated and formalized on every level, and just how many resources and funds are lost while the audit stretches on. Providers should also be aware that mistakes and carelessly worded statements made in the early stages of an audit can return to haunt them when a final decision is made. For these reasons, it is optimal to consult an attorney as soon as the notice of audit is received.

Another key aspect of understanding the audit process is knowing that most CMS contractors are compensated based on the amounts they recover. This means that such contractors have a huge financial incentive to maximize recovery by any means possible.

Providers today know just how much is on the line when they learn that an audit has been initiated. Potentially, the audit can result in crippling overpayment assessments, fines, criminal prosecution, and loss of license. While the audit is pending, the provider will be in the position of having to keep the practice operating while dealing with disruptive site visits and staff interviews, being forced to fill out voluminous and confusing paperwork, and having to direct time and resources to complying with auditors’ demands.

With advanced technology and many new contractors competing for the highest recovery amounts, CMS has enormous resources at its beck and call. The ubiquity of electronic records also gives CMS a huge advantage by facilitating programs designed to sift and analyze data to detect abnormalities or concerning trends for a particular provider, using variables including patient population, specialty, and geographic area. During an audit, a provider’s greatest resource is an experienced attorney with the knowledge and drive to effectively defend the provider’s interests.

Our firm offers assistance to healthcare providers at any stage of dealing with an audit. Whether you just received your audit notice today or you would like assistance with any stage of an appeal, we will evaluate your case and come up with an effective strategic approach. Our highly qualified healthcare attorneys are experienced in handling all aspects of audit defense on behalf of providers.

A thorough understanding of procedure, as well as of the substantive law is necessary for an effective defense. Engaging an experienced and knowledgeable attorney is the best way to ensure that your case is handled correctly throughout. Every case is highly individual and there is no single one-size-fits-all approach. Our attorneys will analyze the facts and apply the law to come up with the best and most effective strategy for your case.

The appeal process can be stressful and confusing, as well as time-consuming and highly disruptive to a healthcare practice. Further, depending on which entity is conducting the audit, the process may differ significantly. It is important that your attorneys be experienced in dealing with all the various types of healthcare audits and preparing a targeted, comprehensive, and effective response strategy. Being able to depend on your attorneys to defend your interests will leave you with the time and energy to do what you do best as a healthcare provider.

Our firm is experienced in defending all types and sizes of providers, from hospitals to one-doctor offices. We deal with audits conducted by Recovery Audit Contractors, as well as other kinds of contractors that conduct audits on behalf of Medicare, Medicaid, and other payors. Our attorneys are deeply familiar with the processes of various contractors and have built up a valuable network of colleagues and contacts that, in many instances, enable them to work quicker and more effectively.

We are committed to putting our experience, knowledge, and resources to work in order to provide you with the defense that is best for your case. Please contact us if you would like to learn more about how we can help you handle your audit.