Providing care to Medicaid patients, although much needed, certainly isn’t easy. There are numerous complex rules you are required to follow as a Medicaid provider. It’s up to you to stay up on these rules and policies to avoid potential pre- and post-payment Medicaid audits, reviews, and referrals. Or for more serious matters, dealings with your state’s Attorney General’s office. Medicaid audit.
While your state Agency may target specific billing practices that trigger a Medicaid audit or review, there are several actions you can take to keep your practice out of your state Medicaid Agency’s sights:
Avoid Irregular Billing Patterns Medicaid audit
Medicaid Agencies have sophisticated claims processing systems that look for irregular patterns of billing errors. These systems are by far the most common way the Agency uses to spot issues with your claims. The top indicates you should look out for are the following:
- Incorrect use of modifiers
- Reporting services use beyond their typical limits
- Reporting services not supported by the listed diagnosis (and vice versa)
- Not billing primary insurance first
Consistently and incorrectly reporting these items may very well earn you a letter from your state’s Medicaid Agency asking for proof or reasoning for a pattern of these billing irregularities. Ensuring your billing staff is up on the latest billing practices as well as regularly reviewing, and understanding, your claim denials can help avoid many of these mistakes.
Note: The claims processing systems is not the only way to be identified for a Medicaid audit. Agencies also receive complaints or tips from beneficiaries when offices repeatedly do things against Medicaid rules. Accordingly, if you have a patient that is unhappy, be sure to listen to them and resolve the problem. You most certainly do not want to get on a Medicaid audit list due to a patient compliant.
Don’t Use Non-Enrolled Medicaid Providers
Properly enrolling your providers in your state’s Medicaid Agency is a must. Medicaid is federally prohibited from paying providers who are not correctly enrolled with them. Repeated claim submissions that include the use of non-enrolled providers will most certainly raise the Medicaid audit red flag.
There can be many reasons that a provider might not be enrolled with Medicaid. Some might include:
- Previously haven’t services Medicaid patients at all, or in your state
- Found guilty of committing a criminal or other offense that prohibits them from participating in Medicaid, or
- Possibly their license type is not accepted by Medicaid for the services you provide.
Regardless of the reason, you are responsible for staying on top of your providers’ enrollment statuses to ensure you don’t allow non-enrolled providers from serving Medicaid patients. To verify enrollment, log-in to your state’s online provider enrollment system or contact their provider helpdesk.
Know Your State’s Policies
Not knowing your state’s policies will not suffice as an excuse for violating policies, and it won’t get you out of a Medicaid audit if you get caught.
It is paramount to stay up to date on policies that apply to the services you provide. This can be done in a few ways:
- Read your state’s Medicaid Provider Manual closely. Examine sections that apply directly to your provider type as well as sections that apply to all providers.
- Pay attention to newly released policy updates. Most states have e-mail listserv subscriptions or update websites you can review regularly.
- Attend any trainings your Medicaid Agency holds.
- Know your Medicaid Agency’s provider helpline number and e-mail if you have questions.
If you are also networked with a Medicaid Health Plan, do all the above through their channels as well
Enlist a Competent/Experienced Biller
Not only will this person keep you from committing costly billing errors resulting in Medicaid audits and takebacks, but they’ll likely be familiar with the rules of other payers like Medicaid and commercial plans.
Medicaid audits and reviews can cover many different aspects of the billing process resulting in a tedious and costly task for you and your staff.
Some states may also conduct random Medicaid audits not related to identified billing errors or complaints. Regularly participate in billing best practices and maintain accurate medical records to ensure your office can tackle any Medicaid audit with confidence. Your state’s Medicaid or Office of Inspector General website may hold additional resources that outline what to expect for these types of audits.
Note: You can find a list of Medicaid state websites on the Medicaid.gov site.
For more information on how to avoid a Medicaid audit, check out this online training by healthcare attorney, Knicole C. Emanuel, JD. This online training is available for you to immediately access. Knicole will walk you through how to head off potentially serious Medicaid triggers before they become a problem. Sign up for this expert-led online training, Reduce Medicaid Audit Triggers and Overpayment Demands, today.
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