What happens when some critical illness catches you in its web and you don’t have money for medical expenses? Generally, Mediclaim policies take care of everything. But everyone is not that lucky. Old age, disowning from relatives, dependent children and suffering from illnesses. The government takes care of such helpless people by organizing Medical assistance programs. Department of health and human service under Medicaid Title XIX organized this program with the help of State and Federal Government. Since the funding has been offered from state as well as the federal government, the medical provider must comply with the requirements under Medicaid fraud audit. It is carried out by State Medicaid fraud control unit.

Who are the beneficiaries of Medicaid and what is fraud audit?

The objective of Medicaid assistance program [Medicaid of title XIX of social Security Act] is to provide payment for medical assistance to low income people (whose income is below 100% federal poverty level), those who are age 65 or more, blind, whose resources do not exceed twice the allowance amount under SSI, disabled or member of family with dependents, pregnant women or small children.  It is imperative that such funds should be handed to proper beneficiaries and should not be misused. The control unit objective is to control provider fraud and administer proper distribution.

What is Medicaid fraud audit?

The control unit carries out audits of Medicaid providers. Auditors have to conduct audits in terms of applicable laws and regulation while auditing providers. The federal law in this case is Title XIX of SSI of 1965 and amended further. The State also lays down certain criteria for validity of payment. It is verified that payments are made only to the eligible provider, the pricing of medicines are appropriate, medical help given is as per approved base. Payments are as per claims only; neither overestimated, nor elevated. No duplication. It is the goal that poor should get the maximum amount help.

medical appointment doctor healthcare 40568 - All You Need To Know About Medicaid Fraud Audit

Procedure for Medicaid fraud audit

Administrative contractors from the Centers for Medicare and Medicaid Services [CMS] will issue letters to providers that they are being audited on scheduled date. The providers are required to produce all records documents, individual records of patients, diagnosis, medication, receipts, hospitalization bills, physician service, administrative charges, properly filled questionnaire and for sample 30-50 patient records are produced. And finally, a site visit is carried out.

What do you do when this happens?

When you receive the letter, check the credentials thoroughly and contact the auditors for verification. Thereafter contact your attorney immediately for preparations. Make sure the adequate staff is present, and the premises are immaculate. Documentation, health records, identification and licenses should be current. Having adequate knowledge about scrutiny policies is always advantageous. Only answer questions from the auditors which you have knowledge of. Do not give false answers. If you do not know anything, say so. If the auditors request copies of certain documentation, try to provide them if you can or explain the issue if you can’t.

Usually it is advisable to ask the auditors if they are especially concerned with anything. It may allow you to reach the root cause and find out why the audit is taking place.