Telling an audit from an investigation
Medicaid defense begins by identifying who is asking and why. An OMIG audit usually seeks repayment of claims it considers unsupported, often by reviewing a sample and extrapolating the result across a larger group of claims. A criminal investigation is a different matter, and in New York it is typically handled by the Attorney General's Medicaid Fraud Control Unit, sometimes alongside federal agencies. Payments can be withheld when the state believes there is a credible allegation of fraud, and exclusion from Medicaid is a separate risk, while a federal exclusion would reach Medicare and other federal programs as well. These tracks can run at the same time, and information given in one can reach the others.
Records, staff, and statements
Respond to records requests completely and on time, but produce documents through counsel so there is a clear record of what was provided. Do not alter or backdate documentation, and do not add late entries to charts without advice, since changes made after an audit begins can be read as evidence of intent. Investigators may contact staff directly, and employees can choose to speak with a lawyer first, although no one should be told not to cooperate. Preserve emails, billing system data, and scheduling records, and suspend any routine deletion. If the organization has already found a billing problem, how it handled that problem internally will be closely examined.
Contesting findings and planning ahead
OMIG audits generally move from a draft report, where the provider can submit objections and supporting documents, to a final report that can be challenged at an administrative hearing within a limited time. Sampling methods and the documentation standards applied to each claim are frequent points of dispute. We review the request or report, the claims at issue, and whether any criminal or federal exposure is present. Then we decide together what to submit, whether to seek a meeting, and how to fix the underlying billing practice going forward.
