Have you received correspondence from Medicaid requiring you to look closely at your billing practices and documentation? Safe Harbor Group can help you navigate the audit process and ensure you’re protected every step of the way. Our team has over 200 years of combined experience and understands the importance of prompt action and expert support.
Do Not Delay Taking Action
These types of letters should be taken very seriously by your organization. Your State Medicaid Agency may have identified suspicious aberrancies in your billed claims and is acting in its capacity to maintain its program integrity and ensure appropriate payments were made. Your State Medicaid Agency collaborates with its jurisdiction’s Unified Program Integrity Contractor (UPIC) to develop processes for investigating and auditing Medicaid fraud, waste, and abuse issues. The UPIC outlines its statement of work. Only with approval from the State Medicaid Agency and the Centers for Medicare & Medicaid Services (CMS) can the UPIC go out into the field to interview practitioners and employees alike, analyze medical claims, and even have the authority to escalate and refer cases to law enforcement after it completes its investigation.
Given the significant implications of Medicaid audits, it is crucial for practices to act in a timely manner by partnering with a trusted compliance firm. Our team of reputable healthcare experts understands the nuanced requirements and complex details found in Medicaid audit letters. Our firm has a proven track record of successfully reducing overpayment demands and eliminating the risk of penalties.
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Customary Medicaid Findings
Do you know what triggered your Medicaid correspondence?
It is a very good idea to understand why you are being identified for a Medicaid audit request letter. CMS utilizes data analytics to pinpoint outliers, or those who go against the average practitioners in their region and their specialty. Some usual and customary reasons can include:
- Volume
- Claims per day (e.g., the medically unlikely day)
- Upcoding services (e.g., increasing E/M code levels)
2. Incorrect coding
- Devices (e.g., electroacupuncture devices)
3. Time-based coding
- Behavioral health (e.g., psychotherapy)
4. Unusual billing patterns
Excessive high-cost items
Excessive services
Customary MedicNew Medicaid Finding
In FY 2024, the Center for Program Integrity (CPI) expanded its audit strategy to include Medicaid managed care program integrity. Much more work performed by UPICs will include capturing quality issues that may impact beneficiaries’ access to care and managed care plans’ provider networks. These factors are crucial to ensuring that Medicaid beneficiaries have access to timely, medically necessary preventive services.
The new strategy will provide greater insight by identifying weaknesses in a state’s processes for monitoring managed care plans’ program integrity activities. Examples include:
- Dollars at risk in the managed care program due to a lack of proper oversight;
- Potential overpayments in capitation payments to managed care plans;
- Potential overpayments to network providers due to a lack of oversight;
- Inappropriate denials of claims for services rendered;
- Inappropriate denial of services, prescriptions, or equipment being sought under prior authorization;
- Inadequate provider networks to meet beneficiaries’ needs
- Shortcomings in the provision of preventive services for children, adults, and pregnant/postpartum females.
Strategies for Success
Entities must arm themselves with knowledge. Understanding the strategies below in navigating a Medicaid audit can ideally save your practice’s reputation and bottom line. Our team recognizes these items as fundamental to garnering swift success:
- Respond on Time: Timeframes for action are most often 30 to 45 days, according to Medicaid audit letters and overpayment demands.
- Review Documentation: Do not just send everything to Medicaid without thoroughly reviewing the documentation and medical records supporting the billed claims. It is recommended to utilize a billing and coding expert who understands reimbursement guidelines to assist in this review.
- Consult with Experts: Enlist a trusted healthcare compliance expert to review Medicaid letters and provide guidance on next steps.
How Can Safe Harbor Assist Healthcare Practitioners Facing Any Type of Medicaid Audit?
Medicaid audits can be stressful for healthcare providers, but there are resources available to assist them. Safe Harbor Group (SHG) specializes in helping healthcare providers with compliance-related issues, including Medicaid audits.
- Conducting internal audits: SHG can audit healthcare providers to identify potential compliance issues and help them prepare for Medicaid audits.
- Responding to audit requests: SHG can assist healthcare providers in responding to Medicaid audits by ensuring they provide complete and accurate documentation to support services billed to Medicaid.
- Reviewing audit findings: If a healthcare provider receives an adverse audit finding, SHG can review the findings and provide guidance on how to respond.
- Developing corrective action plans: If a healthcare provider is found to have compliance issues, SHG can assist them in developing corrective action plans to address those issues and prevent future compliance problems.
SHG’s team of former SIU and certified auditing experts has extensive experience conducting audits and investigations and a deep understanding of Medicaid regulations and compliance requirements. They can provide valuable guidance and support to healthcare providers facing Medicaid audits, helping them navigate the audit process and achieve a positive outcome.
Why Choose Safe Harbor Group for Medicaid Audit Defense in Detroit?
Safe Harbor Group brings deep insight into how Medicaid agencies and UPICs evaluate claims, identify outliers, and escalate cases. Our team includes former SIU professionals and certified auditors who understand what triggers audit letters and how to respond with precision. With extensive experience reducing overpayment demands and addressing complex compliance concerns, SHG offers guidance grounded in real investigative knowledge to protect practices from financial and legal exposure.
Discuss Your Medicaid Audit Today
Medicaid audits can place significant pressure on any practice, but the right guidance can make the process far less daunting. Safe Harbor Group offers the knowledge and support needed to respond effectively, strengthen documentation, and address concerns before they escalate. If your organization has received a Medicaid audit letter or needs help understanding next steps, reaching out promptly can make all the difference. Get in touch today to learn more.
