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Medicaid Audit Defense Attorneys

In 2005, Congress enacted the Deficit Reduction Act of 2005 which led to the creation of the Medicaid Integrity Program (“MIP”). Its focus and goal are to identify improper payments and overpayment of claims submitted to Medicaid. The MIP employs the use of Medicaid Integrity Contractors (“MIC”) to carry out auditing of provider billing records for inappropriate claims and overpayment.

The Medicaid Audit Process

Usually, a provider will receive notice of an audit by mail. The audit itself may take place at the site of the provider’s practice or remotely. During the audit, MICs have no limitations on patient medical records requests and may review claims submitted back to five years prior to the initiation of the audit.

At the end of the Medicaid audit, the MIC will send a detailed report to the provider indicating which, if any, claims submitted to Medicaid were questionable, inappropriate, duplicated and more. The provider has the opportunity to respond to the letter offering explanations, agreement or disagreement with each of the claims at issue within 30 days of receipt.

After the Medicaid Audit

If the audit report contains any findings of inappropriate claims, MIP refers the findings to the state in which the provider resides. It is important to remember, the money Medicaid believes to be owed is paid by the state which then initiates an action against the provider for reimbursement.

In addition to monetary consequences, Medicaid may take a variety of adverse actions against a provider such as:

    • Suspension of payments
    • Suspension of participation in Medicaid and Medicare
    • Referral to Medicaid Fraud Control Unit or Federal Office of Inspector General

These consequences can have serious civil and/or criminal ramifications for providers. While an audit may not seem serious at first, the results of the finding may have a lasting detrimental impact on a provider’s ability to continue to participate in Medicare and Medicaid in addition to potential criminal liability.

Our Audit Defense Attorneys

A Medicaid audit is no minor issue and your rights are affected from initiation and beyond completion. The consequences of the audit report may be very serious, and it is important to have experienced legal counsel by your side. Our Medicaid audit attorneys have been helping health care providers for over 30 years. We understand your livelihood may be at stake and we will work to protect it.

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