If you are a Medicaid provider in New York, you will likely face at least one audit by the Office of the Medicaid Inspector General. Unlike a targeted investigation, an audit does not necessarily mean you are under suspicion for fraud. However, a routine audit does have the potential of giving rise to more serious problems, especially when providers fail to approach the audit correctly.
An OMIG audit usually begins with an audit engagement letter, which should also explain the focus of the audit. Most audits scrutinize your compliance plan (if you fall into the category of providers who must have one by law), Medicaid rate reimbursements or past claims that have been paid to you.
1. Failing to respond to documentation requests
Whatever the purpose of the audit, you will need to provide extensive relevant documentation. You may receive various requests throughout the process, along with a specific timeframe for providing them. It is important to either comply with the request or properly object to it before the deadline.
2. Creating new documentation
Sometimes, you may receive requests for types of documentation that you do not have. Avoid creating documents simply for the purpose of the audit, except for properly dated and clearly designated summaries and memoranda. You never want to create the appearance of purposely fabricating or misdating anything, no matter how seemingly insignificant. If you realize that you were required to keep a certain type of record and have failed to do so, consult with your attorney to figure out how to best address this issue with auditors.
3. Accepting the results of the audit without question
The results of an audit can have substantial consequences for your practice. For example, one of the aims of these audits is to identify overpayments and recover funds. If you do not agree with the auditor's conclusions, you can request a hearing; in some cases, you may be able to appeal the results of that hearing in court.
In some situations, an audit can serve as a starting point for eventual allegations of fraud. Navigating this process correctly can reduce the chances of providing potential evidence against yourself. Although this process is routine, it is far from simple, so it is important to prepare and obtain advice from qualified professionals.