Appealing and Defending Against a Faulty Medicaid Audit
Situation
Healthcare providers constantly face potential audits from Medicare and Medicaid contractors. Often, these audits are faulty and result in overpayments for providers. Our case study explores the process of appealing and defending against a faulty Medicaid audit and the powerful impact these services can have on practices that have been wrongly audited.
Two practices approached us to represent them through a faulty audit. HMS, a Medicaid recovery audit contractor (RAC) for Colorado, audited providers who performed initial visits on patients admitted by the attending physician.
The RAC’s algorithm was faulty, resulting in automated reviews that led to significant overpayments for hundreds of providers in the state, including the practices we represented in this case.
Results
Our audit defense services resulted in significant wins in both cases:
- The first case case was $36,000 and dropped to $0.
- The second case was $127,000 and dropped to $0.
How We Did It
A look at our audit defense services in resolving these cases highlights our determination to expose the truth when appealing against faulty audits:
Engaged With Parties Continually
We approached HMS to appeal the audit, but they refused to engage. Instead, the matter was referred to the office of the attorney general (AG), and they picked it up and engaged with DoctorsManagement.
Pursued the Case Until the Matter Was Resolved
Resolving these cases took over a year. We refused to give in and aggressively led the fight against HMS and the AG’s Office. Throughout this time, we had informal hearings with HMS and the AG’s office. These hearings were often heated as we relentlessly pursued the truth and exposed both parties’ gaps in knowledge.
Exposed the Truth on Behalf of Our Clients
Unfortunately, one of the attorneys working for the AG’s office admitted she had no healthcare knowledge and did not understand what we were presenting.
Additionally, HMS tried to hide behind various lies related to the audits, but we fought to expose the truth for our clients. Our expertise allowed us to use their guidance and manuals against them, forcing the AG’s office to back down.
Through their partnership with DoctorsManagement, both cases dropped to $0. Even though it took us a year to fight these cases, we successfully appealed the faulty audits and defended the two practices that hired us.
