As part of the Centers for Medicare & Medicaid Services (CMS), Medicaid auditors are eager to come after potential instances of fraud or abuse that could cost you a fortune in fines, penalties and exclusions if you aren’t careful.
Check out several areas that Medicaid auditors are targeting, and find out how you can stay on the right side of the law.
Watch for Stark Law Violations
Under the Physician Self-Referral Law, more commonly known as the Stark law, providers cannot refer patients to receive designated health services payable by Medicaid at facilities where the provider or their immediate family members have financial relationships. There are rare exceptions to this rule, but in general, your practice must avoid referring patients for services at places where the provider has a financial interest.
For example: If you invest in an imaging center and one of your Medicaid patients needs an X-ray, you cannot refer the patient to your imaging center for it, unless you meet a Stark exception.
Your practice should ensure that all providers disclose their financial relationships, and you must maintain a listing of those to ensure that you aren’t violating the Stark law provisions, which would set you up for potential fraud accusations that could cost you a fortune if they’re discovered during a healthcare audit.
Monitor for Kickbacks—and Go Beyond Cash
A criminal law known as the Anti-Kickback Statute prohibits providers from knowingly offering remuneration to induce or reward business that involves any item or service payable by federal health programs, including Medicaid.
The term “remuneration” may seem like it applies just to money, but it goes beyond that. In reality, it includes anything of value and can take many forms besides cash, such as free rent, hotel stays, meals, and more.
For instance: Your spine surgeons create a relationship with a local personal injury firm. For every Medicaid patient they send to you for evaluation, you send them a $100 gift card to a local restaurant. This would be considered a violation of the Anti-Kickback Statute.
Stay on the lookout for these types of referrals at your practice, and if anything even gives the hint of being referral-based, you should look into it before auditors do.
Perform Self-Audits to Evaluate Your Billing Patterns
Medicaid payers use data mining to evaluate whether your practice’s billing patterns are out of the ordinary. For instance, perhaps you’re a podiatry practice. Auditors might compare your claims to the claims of other podiatrists in your area. If they notice that you’ve got significantly more billable claims than the others, they may take a closer look, sparking an audit. In some cases, you can do those comparisons yourself ahead of time by reviewing specialty-specific utilization numbers from your payer.
To prevent getting a surprise call from an auditor, you should audit your practice first. Review a sample of claims from each provider and confirm that they are all coded and billed correctly, and that the medical records justify medical necessity for all of the services you performed. If you find discrepancies during your healthcare audit, deal with them immediately by providing education sessions for the providers in question and paying any overpayments back to the Medicaid program.
Perform these self-audits regularly to ensure that you won’t raise any red flags to auditors. Billing claims in unusual patterns is not a violation in itself, so if you submit more claims than your peers, you shouldn’t have anything to worry about as long as you are billing and coding accurately and for medically necessary reasons.
Don’t Immediately Pay Back Medicaid Based on Accusations
If a Medicaid auditor comes to your practice and reports back that you committed violations totaling a small amount, your first inclination may be to pay it, but you shouldn’t do that right away. Why? Because once you pay it, you’re acknowledging your noncompliance, and it could lead to additional fines, penalties, and audits looking for similar violations.
In reality, you should examine every accusation of noncompliance and make sure the auditor is in the right before you pay. In some cases, you may disagree, and it’s within your rights to fight the accusation and work to prove your innocence. It may not seem worth it to fight an audit request for, say, $500, but it could save you thousands down the road.
For more information about how to stay off Medicaid’s audit radar, check out the online training session Master Medicaid Enrollment/Credentialing for Faster Approval & Pay. During this 60-minute session, healthcare attorney Knicole C. Emanuel, Esq., will walk you through the ins and outs of the Medicaid program so you’ll stay compliant.
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