Medicare and Medicaid Audits
If you have received a request for a Medicaid or Medicare audit, or for private carrier audits, it can be a difficult, stressful time. Healthcare providers are required to promptly respond to an initial request for an audit. If you fail to respond promptly, you could find yourself in financial and legal troubles. Additionally, when an audit results in a finding of overpayment, you must be sure to file a request for appeal or review—if you fail to do so, you risk unintentional waiver of the right to appeal or review. When you realize how much is at stake, you understand that hiring an attorney experienced in handling Medicaid, Medicare, and private carrier audits is an absolute necessity.
Rosenberg Law, P.A. has a history of successfully representing Florida healthcare providers who bill Medicaid and Medicare. We help our healthcare professionals respond to requests quickly and accurately, and should further issues arise, we have the knowledge and experience to help you through the process from beginning to end. Additionally, Rosenberg Law, P.A. routinely offers Medicare/Medicaid audit seminars for our clients, providing a more detailed look into the audit process. We also offer comprehensive compliance planning, including staff compliance training. Contact us today if you would like to schedule a Medicare/Medicaid Audit seminar or discuss compliance planning and educational opportunities.
What is a Medicare, Medicaid or Private Carrier Audit?
While it is hoped that you never have to go through a Medicare, Medicaid, or Private Carrier Audit, as a healthcare professional, you should always be prepared for such an eventuality. In particular, the Centers for Medicaid and Medicare Services are working harder than ever to find and stop fraud, waste, and abuse. As a part of such efforts, CMS is involved in numerous audits—which can have a significant impact on day-to-day business operations for the targeted healthcare professional. A Medicaid or Medicare audit is an intensive review of your billing practices—more specifically, an intensive review of the services you have billed to CMS.
In some instances, CMS can request documents dated back years, and may also request very large quantities of these documents. A CMS audit for Medicaid or Medicare may be conducted by CMS, a CMS contractor, or from a federal agency that refers cases to CMS. They post the audits that are being performed. No matter who is doing the auditing, a Medicaid or Medicare audit is always an extremely serious issue—one that can even make it impossible for you to continue your practice until the audit is finalized. A Medicaid audit can even put all payments from CMS on hold—even for 100 percent legitimate services you’ve provided. As a result of the potential serious repercussions, Rosenberg Law, P.A. tracks all the posted audits in order to make the process as frictionless as possible.
There is often a political or financial incentive to Medicaid and Medicare audits; if it is concluded you owe CMS money you can appeal, but the process is highly complex, long and drawn out, and extremely challenging, taking many months, or even years to get through an audit appeals process (the Medicaid audit appeals process is a five-tier nightmare). Most healthcare professionals simply don’t have the financial resources to hang on that long, continuing to treat Medicare and Medicaid patients, while not getting paid.
Private Carrier Audits
A private carrier audit may occur when a third-party payer conducts billing audits through their employees or agents. This is a process to determine whether the data in a healthcare professional’s records include appropriate, referenced medical policies, necessary documents, and support services.
Are There Different Types of Medicaid and Medicare Audits?
While any Medicaid or Medicare audit is serious, there are specific types of audits. Your attorney can explain these different audits more thoroughly. But the type of Medicaid audit you are facing will determine the scope of the audit, the potential penalties, the most strategic responses, and whether you will face other investigations in the future.
An RAC audit occurs when CMS hires a third-party company to monitor billing data from a healthcare professional, a hospital, or a pharmacy. These Recovery Audit Contractors retain a percentage of money collected on behalf of Medicaid, meaning they will go above and beyond to find even the slightest evidence of overbilling. Unfortunately, RAC audits are occurring more and more often.
A Medicare Administrative Contractor audit is similar to an RAC audit, but the MACs will process both incoming invoices and outgoing payments, as well as tracking your billing history. During the audit process, and MAC may even evaluate your treatments regarding medical necessities. A MAC audit can take a very long time and may even trigger a pre-payment review—meaning your billing must be approved by MAC before you can get paid for services rendered.
A ZPIC review (Zone Program Integrity Contractor) involves a private organization who has been given the task of discovering health care fraud, which is a crime. While RACs and MACs are more concerned with recovering money, ZPIC will recommend and refer to other agencies and can suspend CMS payments, or even refer for criminal prosecution.
Finally, the Comprehensive Error Rate Testing (CERT) is meant to identify invoicing trends that are deemed “problematic.” If CERT shows irregularities in your billing process, it is highly likely you will soon be facing a Medicaid or Medicare audit, dealing with RAC and MAC, who both use CERT as a monitoring process.
What are Some “Red Flags” That Could Lead to a Medicare Audit?
Following Medicare’s thick book of rules can be exhausting. Even if you are absolutely certain you are doing everything right, you may, at some point, face a Medicare audit. Generally speaking, the following are considered Medicare audit red flags:
- Any level of sub-par documentation, including missing certifications in the patient’s plan of care, illegible signatures, failure to provide sufficient PTA supervision, the use of a signature stamp, failure to recertify the plan of care, insufficient documentation, failure to supply records to Medicare when asked, and much, much more
- Incorrect billing for services provided by therapy techs or aides
- Knowingly submitting claims for services normally covered by Medicare without providing medical necessity documentation
- Gaming the coding system by “unbundling”
- Billing for services not furnished or billing for a duration that falls outside the norm
- Inappropriate referral of service
How Can You Avoid a Medicaid Audit?
Like Medicare, you also want to avoid a Medicaid audit whenever possible. Make sure you have clearly dated and signed every patient record entry. Always ensure you document the services necessary and completed to support Medicaid billing. Make sure you are in regular communication with your billing person, and never bill for anticipated services. Keep your patient records highly organized, using only one-sided documents, and ensuring prescriptions and sticky notes are securely fastened in the patient’s file. Never allow another physician who is not enrolled as a Medicaid provider to provide services to your Medicaid patients (such as a new physician in your practice) and use only standard abbreviations in your medical records documentations, reports, and orders.
How Rosenberg Law, P.A. Can Help Healthcare Professionals Who are Being Audited
If you are a healthcare professional who is being audited, whether you are facing a Medicare audit, a Medicaid audit or a private carrier audit, Rosenberg Law, P.A. can help. We have helped many healthcare professionals in the same position, with positive outcomes. Our attorneys understand that this is a stressful time for you, and that an audit can disrupt your practice, even keeping you from being paid for services rendered. Rosenberg Law, P.A. will help you get through your audit with the least disruption possible for you and your patients. Contact Rosenberg Law, P.A. today, at our Plantation, Florida location or our Sarasota, Florida location.