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Seven Things To Know When You Receive A Notice Of Investigation From The Department Of Health

Healthcare Professionals: Do You Know How to Prepare For, and Respond To, a Medicaid Audit Request?

By George F. Indest III, J.D., M.P.A., LL.M., Board Certified by The Florida Bar in Health Law

Florida healthcare providers servicing Medicaid patients are at a higher risk for audits than anywhere else in the country. Unfortunately, the unfortunate truth is that Florida has become synonymous with healthcare fraud. As a result, auditing and subsequent overpayment demands are some very real possibilities. Should you find yourself, your facility, or your health practice the subject of a Medicaid audit by your state Medicaid agency or audit contractor, there are a few things you should know.

The most important thing is that just because you are being audited, it does not mean that you or your business has done anything wrong. State and federal governments conduct audits for many different reasons. Typical ones include special audits of high-fraud geographic areas, auditing of particular billing codes, randomly selected provider auditing, and complaints of possible fraud.


How Do You Know If You Are the Subject of an Audit in the First Place?

The process will usually begin with the provider receiving an initial Medicaid audit request, usually by letter or fax.  This request will notify the recipient that it is the subject of an audit.  The initial letter will not always identify the reason for the audit.  What it will contain, however, is a list of names and dates of service for which the auditors want to see copies of medical records and other documentation.

This stage of the process is crucial because it is the best opportunity to control the process.  Once the records are compiled and sent to the auditor, the process shifts and you are now going to have to dispute the auditor’s findings in order to avoid a finding of overpayment.

The biggest mistake that someone who is the subject of an audit can make is to hastily copy only a portion of the available records and send them off for review. The temptation is to think that since the records make sense to you, they will make sense to the auditor. But, remember, the auditor has never worked in your office and has no idea how the records are compiled and organized. This is why collecting a comprehensive set of documents presented in a clearly labeled and organized fashion provides justification for every service or item billed.


How to Survive the Audit Process.

The following are steps that you should take in order to compile and provide a set of records that will best serve to help you avoid any liability at the conclusion of the Medicaid audit process:

1. Read the audit letter carefully and provide everything that it asks for.  It’s always better to send too much documentation than too little.

2. If at all possible, compile the records yourself.  If you can’t do this, have a compliance officer, experienced consultant, or experienced health attorney compile the records and handle any follow-up requests.

3. Pay attention to the deadlines.  If a deadline is approaching and the records are not going to be ready, contact the auditor and request an extension before it is  due.  Do this by telephone and follow up with a letter (not an e-mail).  Send the letter before the deadline.

4. Send a cover letter with the requested documents and records explaining what is included and how it is organized as well as who to contact if the auditors have any questions.

5. Number every records page sent from the first page to the last page of documents.

6. Make a copy of everything you send exactly as it is sent.  This way there are no valid questions later on as to whether a particular document was forwarded to the auditors.

7. Send the response package using some form of package tracking or delivery confirmation to arrive before the deadline.

Compiling all of the necessary documentation can be an arduous task. Suppose you find that you cannot do it on your own, or that there are severe deficiencies in record keeping. In that case, it is recommended that you reach out to an attorney with experience in Medicaid auditing to assist you in the process.

Click here to read one of my prior blogs for even more tips.


Contact Health Law Attorneys Experienced in Handling Medicaid and Medicare Audits.

The Health Law Firm’s attorneys routinely represent physicians, medical groups, clinics, pharmacies, durable medical equipment (DME) suppliers, home health agencies, nursing homes and other healthcare providers in Medicaid and Medicare investigations, audits and recovery actions.

To contact The Health Law Firm please call (407) 331-6620 or toll-free (888) 331-6620 and visit our website at www.TheHealthLawFirm.com.


About the Author: 
George F. Indest III, J.D., M.P.A., LL.M., is Board Certified by The Florida Bar in Health Law.  He is the President and Managing Partner of The Health Law Firm, which has a national practice.  Its main office is in the Orlando, Florida, area.  www.TheHealthLawFirm.com  The Health Law Firm, 1101 Douglas Ave. Suite 1000, Altamonte Springs, FL 32714, Phone:  (407) 331-6620 or toll-free (888) 331-6620.

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