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06 May

Medicaid Suspension and Revocation

Few healthcare providers have a sufficient diversity of payers to survive a suspension or revocation of Medicaid payments; it can quickly lead to ceasing operations and/or bankruptcy. In addition, a Boca Raton healthcare law firm reports that Florida has a law which prohibits the issuance or renewal of a professional license of anyone excluded from the Medicaid program until that individual has been reinstated to Medicaid for at least five years.

Increase in the Medicaid Program

With the full implementation of the Affordable Care Act, the Medicaid program is experiencing unprecedented growth, as many of the new beneficiaries are receiving Federal subsidies for their care.

Increase in Audits

Florida healthcare providers are subject to two different types of audits:

• Recovery Audit Contractor (RAC) process, and
• Zone Program Integrity Contractor (ZPIC) process.

Both operate on a contingency basis, meaning the contractors who operate RAC and ZPIC get paid a percentage of the overpayments their audits uncover. Although some may allege this is akin to a “bounty’ system, a knowledgeable Boca Raton healthcare law firm understands this is how the system will operate in the foreseeable future and providers must be prepared.

The Importance of Representation

Those conducting an audit are seeking broad ranging information and it is essential to provide correct responses to audit questionnaires and provide complete, understandable medical records and supporting documentation from the start. One particular problem with the audit process is the use of what is known as the extrapolation formula. Under this process, if an audit reveals an overpayment in a small sample of claims, it is assumed that the same overpayment will exist in all the claims if individually audited. This can result in a proposed error amount of 50 -100 times the actual error. Other audit issues include the power of the auditor to recommend a suspension prior to fully concluding the audit and the potential for a demand of full repayment prior to completing the appeal process.

Contact a Boca Raton Healthcare Lawyer for Legal Advice

Healthcare providers must be proactive and immediately respond to any Medicaid billing concerns. Understand your rights and obligations. Call Webb Millsaps, a Boca Raton healthcare lawyer, at (561) 900-7238.

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