Medicare & Medicaid Audits in Illinois
Over 40 years of experience defending healthcare providers in Medicare and Medicaid investigations and audits
Medicare Audit Defense
In today’s regulatory environment, healthcare providers are under greater scrutiny than ever before. A single overpayment notice can ask a healthcare 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 healthcare provider’s claims. While some audits are focused on educating healthcare providers and identifying underpayments to healthcare 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 healthcare 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 healthcare 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 healthcare providers who have high denial rates or unusual billing practices. If a healthcare 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 healthcare 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, healthcare 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 healthcare 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 healthcare 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 Defense
The Illinois Department of Healthcare and Family Services (IDHFS) is responsible for administering the Illinois medical assistance program (Medicaid). Approximately 25% of Illinois’s population receives their medical benefits from Medicaid.
The Office of Inspector General (OIG) to IDHFS is responsible for preventing, detecting and eliminating fraud, waste, abuse, misconduct and mismanagement in the medical assistance program. To fulfill these objectives, IDHFS, through its OIG, conducts medical quality and post-payment reviews of goods and services provided to Medicaid beneficiaries by healthcare providers. The OIG may also impose payment suspensions when there are credible allegations that a healthcare provider has committed fraud.
A post-payment review of a Medicaid provider’s claims can result in an action by IDHFS to recover overpayments. Depending on the nature and extent of overpayments identified, IDHFS may also request that the provider be terminated from the medical assistance program. Similarly, findings from a single medical quality review can result in an action to terminate an enrolled provider from Medicaid, if he or she provided grossly inferior quality of care, placed Medicaid recipients at risk of harm, or provided goods or services in excess of recipient needs.
An action by IDHFS to recover overpayments and/or terminate a provider’s enrollment in the medical assistance program involves an administrative hearing process in which the provider has the right to be represented by counsel. In connection with an overpayment and/or termination action, IDHFS may suspend payments to the provider in order to protect and preserve Medicaid funds. A payment suspension can cripple a provider’s medical practice, especially for those providers whose practices are based heavily on services provided to Medicaid recipients. When a payment suspension has been initiated, the provider must successfully defend against IDHFS’s allegations in the termination and/or overpayment action in order for the suspended payments to be released to the provider.
If you have received a termination or overpayment notice from IDHFS, it should not be ignored, as final decisions from such actions have potentially far reaching consequences. The names of providers who have been terminated or suspended from the medical assistance program are maintained on the OIG’s sanction list. In addition, termination from Medicaid may result in the provider also being terminated from Medicare; may result in loss of a physician’s medical staff membership and privileges; and in certain circumstances, may result in disciplinary action being taken against the provider’s professional license.
Final decisions of IDHFS may be appealed to the Illinois courts through an action called “administrative review.” In connection with administrative review, a provider may request the court to stay enforcement of the final decision pending final disposition of the appeal. A complaint for administrative review must be filed within 35 days from the date of the final decision. However, if a stay of enforcement is also required, it may be necessary to act faster. The grounds for appealing a final decision of IDHFS vary depending on the facts and circumstances of each particular case.
The attorney’s at Goldberg Law Group have been representing Medicaid providers at IDHFS for over four decades. Our clients include physicians, dentists, medical groups and clinics, transportation providers, nursing facilities, home healthcare agencies, and other healthcare providers. We routinely represent and advise providers in Medicaid audits, quality reviews, and overpayment and termination actions. We offer distinctive knowledge and insight gained from years of experience representing Medicaid providers at IDHFS that enables us to effectively defend Medicaid providers in quality reviews or termination/overpayment actions. Our healthcare attorneys also regularly represent Medicaid providers during administrative review of final decisions of IDHFS.
Contact Jenna E. Milaeger at 312-930-5600 to learn more about how our attorneys can assist in your Medicare or Medicaid investigation or audit.
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Practice Areas in Illinois
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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The lawyers at Goldberg Law Group provide legal advice and representation in business-to-business disputes and in conflicts that arise amongst individual stakeholders.