Medicaid Audit Defense

The Health Law Firm and its legal professionals represent health care providers in virtually every aspect of Medicaid program audits, investigations and litigation. These include physicians, medical groups, mental health professionals, pharmacies, nursing homes, home health agencies, hospitals and other health facilities.

It is extremely important that the health care provider obtain experienced professional representation in responding to a Medicaid Program audit notice. There are many problematic legal issues that a Medicaid audit seeks to identify in such audits. Correct responses to audit questionnaires and the provision of complete, legible, well-organized, responsive medical records (and other supporting documentation) must be provided. This is crucial from the very beginning.

The receipt of the Provisional Agency Audit Report (PAAR) is another opportunity to provide documents, explanations, medical authority, legal authority and other documentation that may reduce or eliminate any repayment to the Medicaid Program.

After receipt of a demand for an overpayment that may be alleged to be due to the Medicaid Program (in Florida, administered by the Florida Agency for Health Care Administration or “AHCA,” and its contractors), it may still be possible to negotiate a repayment or settlement of the matter on favorable terms.

If not, then The Health Law Firm and its attorneys are experienced in representing the health care provider in formal administrative hearings, in civil litigation or in appeals, on such matters.

Because of the extrapolation formula used by the state Medicaid Program to calculate overpayment amounts, every dollar you are able to prove you are owed on the audit itself may cause you to save $50 – $100 on the final audit.  One of our goals when assisting a Medicaid Provider in a Medicaid audit is to produce sufficient documentation to prove the amounts originally billed and paid were correct.  Every dollar saved in such an audit can yield hundreds in the final results and may even avoid any sort of repayment or penalty assessment. 

Audits routinely result in a provider being assessed tens of thousands of dollars in alleged overpayments, plus fines, penalties or interest on top of that.  For example, in one representative case a provider was found on the audit to have been overpaid the actual amount of $679.00 on the patients audited.  This was extrapolated by the Medicaid Program to result in an overpayment amount of $60,807.70, a ratio of 89.56 to 1.  Click here for actual calculation.

However, it has been our experience in such cases that if a statistics expert is retained to review these calculations, many errors can be discovered.  This may lead to the formula being discarded completely as unreliable in an administrative hearing.  Often incorrect numbers are used, samples are not representative, or other problems are found in the way the sample is taken.

The motto of this story is that it pays to have expert assistance in such matters.

In the event that a health care professional receives a subpoena or search warrant for records concerning a Medicaid criminal investigation, our attorneys are experienced in dealing with investigators and state’s attorneys, including attorneys and investigators working for the Attorney General’s Medicaid Fraud Control Unit, in defending the health care provider and attempting to resolve the case before criminal charges are filed.

We assist providers in obtaining Medicare and Medicaid provider status (provider identification numbers), as well as, in proceedings seeking to revoke or terminate a health care provider’s Medicare and Medicaid provider status. We also advise clients on performing internal audits of Medicare and Medicaid services, billing, reimbursement and on how to make voluntary refunds of overpayments to the Medicare and Medicaid Progams.