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Doing a Medicare audit? Why you need a healthcare attorney

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Whether it is intentional conduct, rouge action of employees, or a simple oversight, false claims and other Medicare issues can have a far-reaching implication on your medical facility. Medicaid & Medicare Services (CMS) are investing a lot of resources to crack down on fraud, abuse, and wastes. To achieve its goal, the agency is involved in a wide range of Medicaid audits, most of which can have a rapid impact on your day-to-day operations.

How Providers Can Detect, Prevent Healthcare Fraud and Abuse

Medicaid audit is always a complex and serious process. It can put you and your practice into months or years of investigative wormhole, making it literally impossible to continue with your business or turn in any gainful profit until the audit is completed. In fact, in some instances, a Medicaid audit can put 100% of your CMS payments on hold until the audit process is completed—and this may even include legitimate services that you may have provided and billed for.

Besides the potential to interfere with your operations, the penalties for Medicaid frauds can be severe. Under the Federal Health Care Law, for instance, you are likely to suffer steep fines or given up to 10 years jail term for a standard Medicaid fraud. In cases involving physical bodily injuries, you may face up to 20 years in prison. Cases involving death may even attract life sentences. Besides, if you are convicted, you can also be barred from participating in any kind of Health and Human Services benefit programs in the future.

Unfortunately, the agencies that are given the responsibility to carry Medicaid audits always have incentives—either monetary or political—to deduce that you committed a Medicaid fraud—and sometimes it involves a lot of money.

Like any other allegation out there, you can always appeal those conclusions, but the process of doing so can be very complex. It can take you several months or years to complete the 5-tier Medicaid audit appeals process. It is really expensive to expend your resources for that long and more demoralizing to continue offering your services to Medicaid patients without being paid.

Hiring a healthcare attorney who is experienced in Medicaid audits to take you through the appeal process is always the most effective way of preventing such audits or ending them as fast as possible in the event that they do happen as well as successfully navigating the whole process when necessary.

How Healthcare Attorney Can Help

The first step in most Medicare fraud cases is carrying an extensive audit. The CMS will send you a notification of the audit and other details of what may be required in the auditing process. This is the stage where you need to contact a healthcare attorney.

Most competent fraud lawyers will try to work out an early resolution before allowing the agency to carry an extensive audit. This may involve authorizing a payout refund or amending certain claims to ascertain that they are valid. An attorney may also help you figure out the viability of coming up with a payment plan depending on the circumstances. Most attorneys will advise you to avoid extensive Medicaid audit because it is a good way of avoiding bad press and continuing with your business normally.

If an extensive audit occurs, all the allegations may need to be challenged or watched closely. This is another area where a healthcare attorney will come in handy. An attorney should be an integral part of the process. He should be ready to follow-up every process that the auditing team will take and appeal any audit or result of any audit that seems to be unfair or unjust.

The bottom line

When your medical practice is on the line because of a Medicare audit, you should make a decisive decision to ensure that you are presenting a strong defense. You cannot do this without the help of a healthcare attorney who understands the intricacies of Medicare audits. To have a positive outcome, therefore, strive to choose an attorney who has the experience of helping his or her clients obtain dismissal of such audits and other types of healthcare fraud claims. Remember that it takes a very special healthcare attorney to successfully fight such charges. If anything, many attorneys will be unwilling to engage in such lawsuits because they involve complicated laws and regulations.