Medicare & Medicaid Audits in Arizona
Medicare Audit Defense
In today’s regulatory environment, health care providers are under greater scrutiny than ever before. Receiving an overpayment notice or a request for medical records from the Centers for Medicare and Medicaid Services (CMS) or one of its contractors can be a stressful experience. A single overpayment notice can ask a health care provider to repay hundreds of thousands or even millions of dollars. A single medical records request from CMS or one of its contractors can ask for information and medical records supporting dozens of Medicare claims. Responding to a medical records request is not a task that should be taken lightly. Not all audits are the same. CMS uses a number of different programs and contractors to review health care provider’s claims. While some audits are focused on educating health care providers and identifying underpayments to health care providers, others are focused on identifying overpayments or even detecting fraudulent billing practices.
If you have received a medical records request from CMS or notification that an audit has been initiated, it is important that you understand the type of contractor conducting the review and the objectives of the audit.
Unified Program Integrity Contractors (UPICs)
UPICs (formerly known as Zone Program Integrity Contractors) perform fraud, waste, and abuse detection, deterrence and prevention activities. UPICs use a variety of techniques to identify and address potentially fraudulent billing practices, including pre-payment review, which can be devastating for a health care provider because the provider must submit documentation and often times complete the appeals process before receiving payment for services rendered.
Medicare Administrative Contractors (MACs)
MACs have many functions, such as handling enrollment issues and claims processing. MACs are also responsible for addressing billing errors involving services that are not covered or not coded correctly. MACs review claims to determine proper payment amounts and adjust or deny payments if the reviewers find the services to be not reasonable or medically necessary, or find that the claims submitted do not properly reflect the services furnished. If the MACs find health care providers whose claims have high error rates, they can put the providers on additional post-payment or pre-payment reviews.
Targeted Probe and Educate Audits (TPE)
The TPE program is used with health care providers who have high denial rates or unusual billing practices. If a health care provider is chosen for the program, the goal is to help him or her quickly improve by identifying common errors in claim submissions. Providers who are selected for this program receive a letter from their MAC notifying of the TPE audit. The MAC will review a sample of the health care provider’s claims and supporting medical record documentation. If some of the claims are denied, the provider is invited to a one-on-one education session and given 45 days to make changes and improve. TPE audits result in overpayments appealed through the Medicare appeals process. In addition to a Medicare overpayment, health care providers and with claims errors following three rounds of TPE review may be referred to CMS for further disciplinary actions.
Comprehensive Error Rate Testing (CERT)
The CERT program was designed to determine the underlying reasons for claim errors and to develop action plans to improve compliance with payment, claims processing, and provider billing requirements. The main focus of the CERT is to obtain a general error rate rather than to identify underpayments or overpayments of a single provider or entity. The CERT contractor randomly selects a sample of Medicare claims and requests medical records and supporting information from the providers who submitted the claims. The CERT sends information on both overpayments and underpayments to the carrier or MAC. The MAC then recovers overpayments or pays underpayments.
Recovery Audit Contractors (RACs)
RACs review claims on a post-payment basis. They identify and correct improper payments through the detection and collection of overpayments and underpayments to health care providers for services provided to Medicare beneficiaries so that the CMS can implement actions that will prevent future improper payments. RACs are paid on a contingent fee basis, and are therefore incentivized to identify overpayments.
If you have received a letter requesting medical records and information relating to Medicare claims, it should not be taken lightly. Requests for medical records sometimes precede other administrative sanctions, such as payment suspension, pre-payment review, revocation, termination, or the imposition of civil monetary penalties. It is important that you contact an experienced health care attorneys who can help you identify the type of audit being conducted and advise you about the audit process itself. Goldberg Law Group’s attorneys represent all types of providers facing audits, investigations, revocations, terminations, exclusions, and other civil and administrative sanctions.
Once an overpayment has been identified, the process for appealing Medicare claims denials is the same regardless of which contractor conducted the audit. The Medicare appeals process contains five levels of review performed by different entities. Each level of review has different time limits for filing. The following is an overview of the Medicare appears process:
The attorneys at Goldberg Law Group devote a substantial portion of our practice handling appeals on behalf of Medicare providers. We are intimately familiar with the process. We can navigate the system for you, or help you to navigate through the system.
Medicaid Audit and Fraud Defense
The Arizona Health Care Cost Containment System (AHCCCS) is responsible for administering the Arizona Medicaid program. According to the AHCCCS, approximately $1.9 million individuals and families in Arizona receive medical services from more than 70,000 health care providers in Arizona.
The Office of Inspector General (OIG) to AHCCCS is responsible for preventing, detecting and recovering improper payments due to fraud, waste, and abuse in the Arizona Medicaid program. To fulfill these objectives, AHCCCS, through its OIG, has authority to take a number of actions to preserve and protect the integrity of Medicaid funds, including:
Issuing subpoenas to enforce the attendance of witnesses, administering oaths or affirmations, examining witnesses under oath, and taking testimony relevant or material to an investigation, examination, audit, or review.
Imposing a civil monetary penalty of up to $2,000.00 for each item or service claimed, and/or an assessment of an amount not to exceed twice the amount claimed for each item or service.
Suspending payments to Medicaid providers where it determines that a credible allegation of fraud exists.
Suspending, terminating, or excluding any person (individual or entity) from participation in the Medicaid program.
Referring cases of suspected fraud to the Medicaid Fraud Control Unit of the Arizona Attorney General for appropriate legal action.
Medicaid fraud can take a number of forms but is generally an intentional deception or misrepresentation made with the knowledge that the deception or misrepresentation could result in a health care provider receiving a benefit he or she would not otherwise be entitled to receive. Some common types of Medicaid fraud include:
Submitting false claims for payment;
Submitting duplicate claims for payment;
Billing for services not provided;
Using unlicensed or unqualified staff to provide services;
Billing services under the wrong provider’s identification;
Receiving kickbacks for referring Medicaid patients;
Using the wrong billing code to receive a higher rate of reimbursement; or
Falsifying information in the medical record.
Unfortunately, there are more ways in which Medicaid fraud can be committed. The OIG routinely monitors billing patterns to look for suspected cases of fraud. Honest billing mistakes do occur, and may result in a health care provider being falsely accused of defrauding the Medicaid program. A large number of billing errors can lead to an investigation and the investigation can lead to charges as if the errors were intentional. But it is the responsibility of the government to prove that the errors were intentional.
If you have received notice of a Medicaid audit or investigation by AHCCCS, it should not be ignored, as final decisions from such actions have potentially far reaching consequences. Cases of suspected Medicaid fraud may be referred to the Arizona Attorney General for prosecution, may result in payment suspension, or may conclude with the provider being suspended, terminated or excluded from participating in the Medicaid program. The names of providers who have been suspended, terminated or excluded from the Medicaid program are maintained on the OIG’s sanction list. Consequently, suspension, termination or exclusion from Medicaid may result in the provider also being terminated from Medicare; may result in loss of a physician’s membership and privileges at hospitals and health care entities; and in certain circumstances, may result in disciplinary action being taken against the health care provider’s professional license.
The attorney’s at Goldberg Law Group have been representing health care providers in Medicaid post-payment review, fraud investigations, and termination/exclusion actions for years. Our clients include physicians, dentists, medical groups and clinics, transportation providers, nursing facilities, home health care agencies, and other health care providers. We routinely represent and advise providers in Medicaid audits, fraud investigations, and overpayment and termination actions. We offer distinctive knowledge and insight gained from years of experience representing Medicaid providers that enables us to effectively defend our clients.
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Practice Areas in Arizona
Our attorneys are vigorous advocates for physicians in medical staff hearings and appeals. We work hard to protect and preserve the rights of Illinois and Arizona physicians under the medical staff bylaws and state and federal laws and defend adverse actions that threaten your membership and privileges.
Medicare & Medicaid Audits
In the current regulatory environment, healthcare providers face increasing scrutiny from government healthcare programs. Goldberg Law Group provides strategic legal representation in all types of Medicare and Medicaid audits and claim reviews.
Third Party Payer Audits
Third party payer audits present a significant financial risk for physicians, industry service providers, and medical groups. Our attorneys have years of experience representing physicians and other providers in in audits and claim reviews initiated by commercial payers.
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