What Are You Going to Do When the Medicaid Auditor Comes Knocking?

Medicaid has significantly greater authority than a private HMO or non-government operated third party provider. It is important to remember that an audit by Medicaid and possibly a Medicaid HMO, might not only be looking for money to be returned but also to revoke your provider status and exclude you from the program. They may even press for further actions if real instances of criminal violations are uncovered in the audit. It is important to know your rights and how to handle any Medicaid audit and investigation since auditors often abuse their authority or use tactics that can cause you to respond in a way that you normally would not. Steps one can take to protect against and minimize the impact of such intrusions or investigations, vary depending on the practice, specialty and individual conduct of the auditors.

  • It is possible to control the timing of the audit if the provider can demonstrate to Medicaid that the audit significantly interferes with the quality of patient care. It is important to remember, however, that this must be more than a minor inconvenience.
  • Often auditors lose or mix up parts of records so it is important to oversee their review and copying process.
  • Additionally it is important to take note of what records and charts were reviewed so that you can perform a self audit with the aid of an expert to look for any deficiencies in your records prior to the completion of any review by Medicaid.
  • An active compliance plan with proper compliance records of self auditing and protocols can help minimize the intensity of any random audit.
  • Presenting the auditors with information of an attorney can also deflect any questions being asked directly of the provider but this must be done in a way that will not appear non-compliant.

Important points to remember in any Medicaid audit:

  1. In most instances you must permit entry.
  2. Keep records of exactly what is taken and monitor the activities of the auditors.
  3. Make notes of the questions the auditors ask and arrange to provide answers at a later time. Try to avoid answering questions on the spot.
  4. Disclose any compliance plan or self auditing activities
  5. Use passive tactics to avoid appearing non cooperative.

The Medicaid audit, which it can be inconvenient, does not have to bring your practice to a screeching halt.

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