Medicare and Medicaid Audit Defense

Mr. Rosenblat’s defense of providers facing Medicare and Medicaid audits is unrivaled. Mr. Rosenblat built his reputation by first working as the chief prosecutor in the Illinois Medicaid Fraud Control Unit and then in private practice. When faced with an audit and recoupment, his thorough knowledge of Medicare and Medicaid regulations, manuals, and local coverage determinations, coupled with his ongoing research to stay updated on any changes, equips him with the knowledge, expertise, and presentation skills to challenge the determination of the auditing contractor. As a Chicago Medicare audit defense attorney, he will not hesitate to engage a trusted and well-respected consulting firm if necessary to challenge the contractor’s extrapolation based on the audited sample.

Mr. Rosenblat’s reputation for outstanding results is highlighted by his representation of a medical practice facing a $1.6 million Medicare recoupment. Appeals were filed with the QIC, Qualified Independent Contractor, and the Office of Medicare Hearings and Appeals. The final decision from the administrative law judge resulted in an overpayment of only a few hundred dollars. In another matter, a physician was accused of submitting false claims to Medicare based on a Department of Justice investigation. The United States Attorney’s original demand letter had single damages of over $400,000. The matter settled for single damages of just $37,500. (This was not an ability to pay settlement, and the provider did not face any collateral consequences.) In a Medicaid audit, a laboratory received a demand letter after a Medicaid audit seeking recoupment of over $341,000. The final overpayment determination was about $2,700.

Various entities can conduct Medicare audits from a United States Attorney’s Office to a paid contractor. Most USAO investigations will seek double damages based on the loss or recoupment amount since their investigation would most often be under the False Claims Act, which allows for treble damages plus a penalty for each false claim. If the investigation is criminal, the USA would likely seek a conviction under the health care fraud statute. (18 USC 1347)

Medicare also employs private contractors to conduct audits and seek recoupments. These private contractors included:

Recovery Audit Contractors are known as RAC’s. RAC’s review post-payment claims to detect and correct improper payments to permit CMS, a fiscal intermediary (FI), or Medicare Administrative Contractors (MAC) to implement steps to prevent future erroneous payments. In Illinois, the RAC is Performant Recovery, Inc.

Medicare Administrative Contractors are known as MAC’s. A MAC processes Medicare Part A, Part B, or durable medical equipment (DME) claims for Medicare. MAC’s are the contact between Medicare and the providers, MAC’s process fee for service claims (FFS). Currently, there are 12 MAC’s and four DME MAC’s. The current MAC for Illinois is National Government Services, Inc.

Zone Program Integrity Contractors, known as ZPIC’s, are tasked to investigate fraud, waste, and abuse by healthcare providers. ZPIC’s conduct audits of healthcare providers on behalf of CMS. Unlike other contractors, RAC’s and MAC’s, ZPIC’s concentrate on fraud allegations, not billing errors. As such, ZPIC audits are more likely to result in a referral to federal law enforcement.

Medical claim audits can result in substantial recoupments, the suspension of payments, being barred from the Medicare program, and even criminal prosecution. As a healthcare audit and defense lawyer, Mr. Rosenblat can develop an effective response to eliminate or mitigate the audit, recoupment, or criminal prosecution. The firm is designed to defend health care providers, physicians, dentists, laboratories, and home health agencies efficiently and effectively from allegations of overbilling to fraud. Mr. Rosenblat’s representation has saved his clients hundreds of thousands of dollars in recoupments and avoided criminal prosecution.

 Contact the firm today for a consultation.