Winning Medicaid Audit Appeals

Winning Medicaid audit appeals (or MIC audits), often depends on the statistical extrapolation which determines how much you will owe in claims.

Medicaid Audit Appeals are very similar to the process in Medicare, but with some important differences explained here.

As with a Medicare Appeal,  one of the most important parts of the review process is the Medicaid Audit Statistical Extrapolation, which based on the review of a small number of billing claims, is applied to all of your claims for a number of years.

It’s the extrapolation of the error rate of the claims that pushes the amounts so high.

Barraclough’s Litigation Strategy is to show that the extrapolation is incorrect. We disprove the validity of the statistics in your favor, so the amount you owe is either nothing or significantly less than originally asked for.

Please read our previous blog, Winning Medicare Audit Appeals for information on Medicare Appeals and the Barraclough Litigation process.

Medicaid vs. Medicare Audits

Here’s a  comparison between Medicare and Medicaid Audits. It’s important to note that since each State has different regulations, a health care provider may have a better chance of winning an appeal in the Medicaid area than in the Medicare process.

Medicaid and Medicare Audit Differences

Medicaid Chart-JFA Revised 2

The Barraclough Advantage for Winning Medicaid Appeals

Credentials matter in MIC audit appeals because rules apply to expert witnesses, and it is in Medicaid audits that  statistics can really make a difference. Barraclough’s expert team of statisticians is a significant asset in all appeals, but this is particularly true in MIC audit appeals.

Statistical examinations are different for the 50 States. Some States have very specific rules about how the statistics work. Barraclough will meet all of these State statistical requirements.

Local expertise is important since rules differ from State to State the rules regarding statistics and how the audits are done.  Barraclough has worked in many States and has the local knowledge, including the knowledge from previous cases

A strong discovery process is a key in winning a MIC audit appeal. With each State, discovery can be used as a tool to defeat the audit results.

Medicaid Audit Process Background

Medicaid Integrity Contract (MIC) audits are  conducted by private companies under contract to the Medicaid Integrity Group (MIG) of CMS.

MIC audits are contracted by CMS and paid under that contract. This is unlike Medicare RACs which are paid based on the amount of money in improper payments they identify.

Like the Medicare RACs, the  MIC audit utilize sampling and extrapolation. MIC audit sampling and extrapolation decisions take into account the circumstances of the particular audit and the laws and regulations of the State to which the provider submitted its Medicaid claims. Audit look backs are allowed for up to five years.

The MIC audit will use a variety of data during the audit process, including, but not limited to, Medicaid claims data, recipient medical records, and other provider records.

The States are responsible for collecting over payments from providers.

The MIC Audit Process

  • MIC auditors perform field audits and desk audits.
  • The MIC auditor prepares a draft audit report, which is first shared with the State and  then with the provider.
  • The State and the provider each have an opportunity to review and comment on the draft report’s findings. CMS will consider these comments and prepare a revised draft report.
  • CMS allows the State to review the revised draft report and make additional comments. CMS then finalizes the audit report, specifies any identifies overpayment, and sends the final report to the State.

The State will then pursue the collection of any overpayment in accordance with State law. Providers have full appeal rights under State law.

MIC auditors can examine:

  • Provider financial records
  • Client medical records
  • Employee records
  • Provider appointment books
  • Any other applicable records related to services billed to the Department

MIC audits may review claims looking back up to 5 years.

For More Information