Medicaid Audit Lawyer

A Medicaid audit can turn into a demand to repay hundreds of thousands of dollars, a referral for fraud prosecution, or exclusion from the program, often based on a small sample of claims that auditors extrapolate across all of your billing. In New York, most Medicaid audits are conducted by the Office of the Medicaid Inspector General, and how you respond to that first audit letter shapes everything that follows, including whether the matter stays civil or becomes criminal. Because much of an audit dispute is about documentation and statistical methods, these matters are frequently defensible, but only with the right lawyer and an early response. If your practice is facing a Medicaid audit in New York City, an experienced Medicaid audit attorney should be your first call.

Varghese & Associates, P.C. is a federal criminal defense firm on Wall Street, in the heart of the Southern District of New York. Medicaid audit defense is part of our Medicaid fraud defense practice, and the firm is led by Vinoo Varghese, a former prosecutor and one of the most recognized criminal defense attorneys in the country. Our Medicaid audit attorneys handle these matters in house, from the first audit letter through the overpayment demand, the administrative appeal, and any fraud investigation that follows. Matters are not routed out to other firms.

Call now for a confidential consultation with a New York City Medicaid audit lawyer. The earlier our Medicaid audit defense lawyers are involved, the more they can do.

What Is a Medicaid Audit?

A Medicaid audit is a review of a provider's claims, medical records, and billing to determine whether Medicaid payments were proper, and it can result in a demand to repay alleged overpayments, referral for fraud prosecution, or exclusion from the Medicaid program. In New York, audits are primarily conducted by the Office of the Medicaid Inspector General, and also by Medicaid managed-care plans and federal contractors. An audit is not the same as a fraud charge, but it can lead to one. Treating an audit as a routine paperwork matter is a serious mistake, because the provider's responses and records become the foundation for whatever comes next.

Who Conducts Medicaid Audits in New York?

Medicaid audits in New York are conducted mainly by the Office of the Medicaid Inspector General (OMIG), along with Medicaid managed-care plans and federal recovery audit contractors, while the Attorney General's Medicaid Fraud Control Unit handles matters that become criminal. OMIG has broad authority to review records, demand repayment of overpayments, and refer suspected fraud for prosecution. An audit can begin as a routine review, a data-driven flag, or a follow-up to a complaint. Because an OMIG audit can quietly become the basis for a criminal referral, having counsel involved from the first letter is the best protection.

What Are the Types of Medicaid Audits?

The main types of Medicaid audits are desk audits, in which records are requested and reviewed remotely, field audits, in which auditors review records on site, and self-disclosure and managed-care plan reviews. Each has its own procedures and deadlines, and each can lead to an overpayment determination. Some audits focus on specific billing codes or services, while others review a broad sample of a provider's claims. Understanding what kind of audit you face, and what the auditors are actually looking for, is the first step in responding effectively.

Why Is Extrapolation So Important in a Medicaid Audit?

Extrapolation is the practice of reviewing a small sample of claims, calculating an error rate, and then projecting that rate across all of a provider's Medicaid billing, which can turn a handful of disputed claims into a demand for hundreds of thousands or millions of dollars. Extrapolation is where many audits are won or lost, because the statistical methods auditors use are open to challenge. If the sample was too small, not random, or improperly analyzed, the entire extrapolated demand can be undermined. Our Medicaid audit attorneys work with statistical and clinical experts to attack flawed extrapolation and cut the demand down to what the actual claims support.

What Happens After a Medicaid Audit?

After a Medicaid audit, the auditor typically issues a draft or final audit report and an overpayment demand, and the provider has a limited time to respond, submit additional documentation, and request an administrative hearing to challenge the findings. Missing those deadlines can forfeit the right to appeal and make the overpayment final. A strong response can reduce or eliminate the demand by supplying documentation the auditors overlooked, correcting factual errors, and challenging the methodology. The administrative appeal, before an impartial hearing officer, is often the most important stage, and it is one our Medicaid audit defense lawyers prepare for from the start.

When Does a Medicaid Audit Become a Criminal Case?

A Medicaid audit becomes a criminal case when auditors conclude that the billing problems reflect intentional fraud rather than error, and they refer the matter to the Attorney General's Medicaid Fraud Control Unit or federal prosecutors. The line between a civil overpayment and criminal fraud is intent. That is why what you say to auditors and how you respond to the audit matters so much, because casual statements or altered records can push a civil matter across that line. Keeping an audit civil, and out of the hands of criminal prosecutors, is one of the most important things a lawyer can do. Learn more on our Medicaid fraud defense page.

What Are the Consequences of a Medicaid Audit?

The consequences of a Medicaid audit can include repayment of alleged overpayments with interest, penalties, referral for civil False Claims Act liability, exclusion from the Medicaid program, and, if fraud is alleged, criminal prosecution. For many providers, an exclusion or a large repayment demand is a practice-threatening event on its own. Because these consequences build on the audit findings, the most effective time to influence the outcome is early, while the audit is still being conducted and before the findings harden into a final demand or a referral.

What Are the Defenses in a Medicaid Audit?

Medicaid audits turn on documentation and statistical methods, and that is where the defenses concentrate. Every matter is different, but the strategies our Medicaid audit attorneys commonly use include:

• Producing the documentation. Supplying records that support claims the auditors marked as unsupported.
• Challenging extrapolation. Attacking the sample size, randomness, and statistical methods behind the projected demand.
• Medical necessity. Showing the services were appropriate and supported by clinical judgment.
• Correcting auditor errors. Identifying misread records, wrong codes, and factual mistakes in the audit findings.
• Distinguishing error from fraud. Demonstrating that any billing problems were good-faith mistakes, not intentional.
• Meeting every deadline. Preserving appeal rights and the right to a hearing.

What Should You Do If You Receive a Medicaid Audit Letter?

If you receive a Medicaid audit letter or a records request, do not ignore the deadlines, do not submit records or talk to auditors without reviewing everything carefully, and do not alter or create any records. Call a Medicaid audit attorney immediately. How you respond to the initial request shapes the entire audit, and altering or backdating records can turn a civil audit into a criminal case. Gather and preserve your documentation, and let your lawyer manage the response and communications with the auditors. An organized, well-counseled response is the single best way to control the outcome.

How Our Medicaid Audit Attorneys Can Help You

Our Medicaid audit defense lawyers defend these matters at every stage, and they look for the earliest possible point at which the demand can be reduced or eliminated:

• Managing the audit response. Handling records requests and communications so the provider does not make the situation worse.
• Attacking extrapolation. Working with statistical and clinical experts to challenge the sampling and projected demand.
• Administrative appeals. Preparing and presenting the case at the administrative hearing to overturn or reduce the overpayment.
• Keeping it civil. Working to prevent an audit from turning into a fraud referral, and defending any criminal exposure if it does.
• Protecting enrollment and licensure. Coordinating the audit defense with Medicaid exclusion and licensing consequences.
• Negotiating resolution. Seeking settlements that resolve the overpayment on manageable terms.

How Much Does It Cost to Hire a Medicaid Audit Lawyer in New York City?

The cost of a Medicaid audit lawyer in New York City depends on the size of the audit and overpayment demand, the volume of records, whether expert extrapolation analysis is needed, and whether the matter goes to an administrative hearing. These matters involve extensive record review, statistical analysis, and hearing preparation, so they require real work. Our Medicaid audit attorneys are transparent about fees from the first conversation and structure the representation to fit the matter. Given that the demand, your Medicaid enrollment, and the risk of a fraud referral are all at stake, the more important question is usually what an inadequate response can cost you.

A Medicaid Audit Attorney the National Media Turns To

When the biggest federal cases in the country are in the news, networks and newspapers call Vinoo Varghese to explain what is really happening in the courtroom. That is the same judgment and credibility our Medicaid audit attorneys bring to your case.

Vinoo Varghese has provided legal analysis and commentary for CBS News, Fox News, Fox Business, CNN, MSNBC, Court TV, HLN, BBC, Inside Edition, i24 News, Sky News Arabia, and Nancy Grace's Crime Stories, and has hosted true-crime legal analysis for Vanity Fair. He has been quoted as a legal authority by The New York Times, The Wall Street Journal, the New York Law Journal, Law360, the New York Daily News, and the New York Post. A former prosecutor from the Brooklyn District Attorney's Office, he is a nine-time National Trial Lawyers Top 100 honoree, an eight-time New York Metro Super Lawyer, rated AV Preeminent by Martindale-Hubbell, and has served on the visiting faculty of Harvard Law School's Trial Advocacy Workshop.

Contact a New York City Medicaid Audit Lawyer Now

If you have received a Medicaid audit letter, an overpayment demand, or a records request anywhere in New York City, do not wait and do not respond on your own. Medicaid audit defense is part of our broader Medicaid fraud defense practice, and a Medicaid audit attorney who has stood in the courtroom and handled these matters can change what happens next.

Call Varghese & Associates, P.C. for a confidential consultation. Our office is located at 2 Wall Street, Suite 310, New York, NY 10005, steps from the federal courthouses of the Southern District of New York.