There is no such thing as a “routine” Medicaid audit. If you have been selected for an audit, it means that the government suspects you have engaged in overbilling or fraud. You must take any Medicaid audit seriously, because it can lead to claims for restitution, exclusion from the Medicaid program, suspension or revocation of your professional license, and even criminal charges.
Medicaid audits are conducted by the Office of Medicaid Inspector General (OMIG) and Medicaid Recovery Audit Contracts (RACs). The auditors are trained to look for compliance issues, potential overpayments, patient abuse or mistreatment, kickbacks and self-referrals, and evidence of Medicaid fraud.
Auditors may conduct the audit at your offices, or they may conduct a “desk audit” at their own offices based on records you provide. The auditors will examine a large sample of individual claims and patient records in detail. They will also compare your claim patterns against the claims of similar providers in the same geographic region.
Audits are often triggered by computer models that identify discrepancies in claims or higher numbers of claims compared to other professionals in the same area. Audits may also be triggered by complaints from patients, a whistleblower, or a Medicaid managed care plan.
OMIG has the power to bring civil and administrative enforcement actions against you to recover overpayments and damages for fraud, abuse, illegal or inappropriate acts, or unacceptable practices. OMIG may also exclude you from the Medicaid program, which can lead to you being excluded from the Medicare program as well. Exclusion means that you cannot bill for any services provided to a Medicaid or Medicare patient.
While OMIG does not have the power to bring criminal charges against you, it will refer your case to the Attorney General’s Medicaid Fraud Unit for criminal prosecution if it suspects that you have engaged in Medicaid fraud.
Our lawyers take a pro-active approach to Medicaid audits. We work with you to ensure you submit sufficient information to support your claims and to help avoid overpayment demands. And if OMIG and a Medicaid RAC finds problems with your claims, we negotiate with them in an effort to resolve any issues or problems without civil actions or criminal charges.
Time is not on your side. You should consult with an experienced Medicaid attorney as soon as you learn that you are the subject of an OMIG or Medicaid RAC audit. To schedule a consultation, call John Howley, Esq. at (212) 601-2728.