Medicaid and Medicare Audit Defense in Illinois
Over 40 years of experience as Medicare and Medicaid audit attorneys defending healthcare providers in Illinois
Medicaid and Medicare Audit Defense in Illinois
Healthcare providers in Illinois often face scrutiny from state and federal government healthcare programs (e.g., Medicare and Medicaid). A Medicaid or Medicare audit can create significant financial exposure for a provider, can result in a payment suspension, or even loss of program participation. Overpayment demands may seek repayment of hundreds of thousands or more, while medical record requests often require providers to compile extensive documentation supporting claims for multiple patients or services.
Not all audits serve the same purpose. Some are intended to correct billing errors, while others are designed to recover alleged overpayments or investigate potential fraud, waste and abuse. Understanding who is conducting the audit and why is critical to protecting your practice.
The Medicaid and Medicare audit defense attorneys at Goldberg Law Group represent healthcare providers throughout Illinois, including the Chicago area, in audits, investigations, and appeals.
Understanding Illinois Audits
The Centers for Medicare & Medicaid Services (CMS), through its contractors, conducts audits of healthcare providers in Illinois. Each contractor has distinct objectives. Understanding the type of audit you are facing is essential to protecting your practice.
Integrity Contractors and Fraud Detection Reviews
Unified Program Integrity Contractors (UPICs), formerly known as Zone Program Integrity Contractors (ZPICs), are responsible for identifying and addressing fraud, waste, and abuse in the Medicare program. UPICs employ sophisticated data analysis and investigative techniques to identify providers for:
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Pre-payment review
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Post-payment audits
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Referrals for payment suspension
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Referrals for revocation or termination of billing privileges
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Further enforcement actions
A UPIC audit can be particularly devastating as these contractors often use statistical sampling to extrapolate overpayment findings to a broader universe of claims. Moreover, UPIC contractors often conduct a series of post-payment audits over a period of time to evaluate provider compliance and make referrals, where necessary, for enforcement actions or for revocation of billing privileges.
Billing Oversight by Medicare Administrative Contractors
Medicare Administrative Contractors (MACs) process claims, manage provider enrollment, and review billing accuracy. MAC audits often focus on:
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Medical necessity determinations
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Coding and documentation errors
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Services not covered by Medicare
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Improper billing patterns
Providers with high error rates may be placed on post-payment or pre-payment review, impacting cash flow and operations. A knowledgeable Medicare audit defense attorney can help challenge denials and guide providers through corrective action plans.
Targeted Probe and Educate Compliance Reviews
The Targeted Probe and Educate (TPE) program targets providers with high denial rates or unusual billing practices. Providers selected for TPE receive a notice from their MAC and are subject to:
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Review of a sample of claims
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Denials and overpayment determinations
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One-on-one education sessions
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Additional rounds of review if issues persist
Failure to improve after three rounds of TPE review may result in referral to CMS for further disciplinary action, making early legal guidance from Medicaid audit defense attorneys critical.
Comprehensive Error Rate Testing (CERT)
The CERT program measures the overall accuracy of Medicare payments nationwide. Although CERT audits are not designed to target individual providers, they still require providers to submit complete medical records and supporting documentation. CERT findings may result in overpayment recovery or underpayment reimbursement through the MAC.
Recovery Audit Contractors (RACs)
Recovery Audit Contractors (RACs) conduct post-payment audits to identify improper payments. Because RACs are compensated on a contingency fee basis, they are incentivized to identify overpayments. RAC audits often involve complex extrapolation methodologies that can dramatically increase alleged repayment amounts.
Why Medicare Audits Should Never Be Ignored
Requests for medical records or audit notices may precede serious administrative sanctions, including:
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Payment suspension
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Pre-payment review
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Revocation or termination of Medicare enrollment
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Civil monetary penalties
The Medicare audit defense lawyers at Goldberg Law Group represent providers facing audits, investigations, revocations, terminations, exclusions, and other administrative sanctions throughout Illinois.
Once an overpayment is identified, providers must navigate the five-level Medicare appeals process, each with strict deadlines and procedural requirements. Our attorneys devote a substantial portion of their practice to Medicare appeals and can manage the process on your behalf or work closely with you to protect your rights.
Illinois Medicaid Audits and State Enforcement Actions
Illinois Medicaid is administered by the Illinois Department of Healthcare and Family Services (HFS) under the Illinois Public Aid Code (305 ILCS 5/). This statutory framework grants the state broad authority to audit providers and impose sanctions.
The Office of Inspector General (OIG) at HFS pursues recovery actions against providers, medical quality reviews, and fraud investigations. Under state law, the OIG may:
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Demand repayment of alleged overpayments
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Issue subpoenas for records and testimony
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Impose payment suspensions
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Recommend suspension, termination, or exclusion from Medicaid
Overpayment Demands, Terminations, and Payment Suspensions
Medicaid audits can result in payment suspensions, recovery actions and provider termination proceedings. Payment suspensions can severely impact providers whose practices rely on Medicaid reimbursement.
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Medicaid Fraud Investigations and the Illinois MFCU
Audit findings may also be referred to the Illinois Medicaid Fraud Control Unit (MFCU), which investigates and prosecutes Medicaid provider fraud. Allegations may include false claims, improper billing, documentation issues, or use of unlicensed staff. Importantly, billing errors are not fraud unless the government proves intent, and experienced legal representation is essential to protect providers’ rights.
Administrative Hearings and Judicial Review
Providers facing overpayment recovery actions or termination actions are entitled to an administrative hearing before an Administrative Law Judge. Final decisions may be appealed to Illinois courts through administrative review, often under strict deadlines. In some cases, emergency action is required to seek a stay of enforcement.
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​The Medicaid audit defense lawyers at Goldberg Law Group regularly represent providers in administrative hearings and judicial review proceedings throughout Illinois.
Choose Goldberg Law Group for Medicaid and Medicare Audit Defense
Goldberg Law Group has represented healthcare providers in Medicaid and Medicare audit defense in Illinois for decades. Our clients include physicians, dentists, medical groups, clinics, nursing facilities, home health agencies, transportation providers, and other healthcare entities.
We offer:
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Deep knowledge of Illinois Medicaid law and HFS procedures
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Extensive experience with CMS contractors and federal audits
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Strategic defense focused on financial, licensure, and reputational protection
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Representation for providers in Chicago and throughout Illinois
Healthcare providers rely on Goldberg Law Group for guidance grounded in decades of experience across our Illinois practice areas and our focused representation of physicians through our lawyers for doctors practice. Our clients benefit from the collective knowledge and hands-on approach of our experienced attorneys.
If you are facing a Medicaid or Medicare audit, overpayment demand, payment suspension, or investigation, time is critical. Early legal intervention can make a difference in the outcome of your case.
Contact Goldberg Law Group today to speak with a Medicaid audit defense lawyer or Medicare audit defense attorney in Illinois.
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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