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When faced with a Medicaid audit, providers may question the audit's methodology and results as the basis for a legal appeal.
Whether republican, democrat or independent, everyone agrees on one thing- Medicaid fraud is bad. Bad for tax payers, Medicaid recipients, and the healthcare system. Very bad for those convicted of fraud, who face not only stiff fines or sentences, but lifetime exclusion from participation. Even the allegation of Medicaid fraud can be extremely damaging, since the Affordable Care Act grants sweeping powers to state Medicaid authorities to suspend payments to any provider who is deemed to face credible fraud allegations, as has been seen in recent high-profile cases in California and New Mexico.
Allegations of fraud can flow into Medicaid authorities via customer complaints, internal whistleblowers, managed care organizations, and relatively new Medicaid recovery audit contractor (RAC) programs. According to Knicole Emanuel, attorney and partner at the law firm Williams Mullen, RAC programs had been around for Medicare and had recovered over $1.03 billion in overpayments, so the federal government decided that RAC programs ought to be mandated for state Medicaid programs as well. These Medicaid RAC programs are tasked with identifying overpayments and underpayments to providers through the use of audits and other program-integrity tools. RACs also receive a percentage of any overpayments they are able to recoup.
Emanuel, who once served as counsel to North Carolina's Medicaid program, now represents Medicaid providers in North Carolina who are undergoing audits, who have had suspensions of Medicaid payments, and who have had issues with their Medicaid contracts. Her experiences, and those of her clients, suggest that if a provider is confronted with the results of a RAC audit alleging waste, abuse or fraud in their Medicaid billings, it may be essential to question the audit's methodology and results thoroughly as the basis for a legal appeal.
According to Emanuel, "We appeal every one ol these [audits] and we try to decide whether we want to appeal the extrapolations or the audit itself, and whether we want it to be an informal appeal that goes to the office of administrative hearings, or state court."
She says extrapolations that are typically used in Medicaid audits have been quite a source of interest lately for...