Status Update on NC Medicaid Audits

Health care providers that accept Medicaid in North Carolina are under fire.  Since North Carolina is one of 7 states undergoing massive, federally-Medicaid audits, all providers, from speech therapists to dentists to psychiatrists to hospitals to nursing homes to radiologists are ALL under fire.  Yet, many providers who are reading this are thinking, “I haven’t been audited yet. Maybe I’m safe.”  My answer? Maybe your particular service has not yet been audited.  Most providers have not yet undergone the intense scrutiny of today’s Medicaid audits by a third-party contractor, but it is only because the state has yet to get to that specific health care service.  Believe me, these audits have only just begun…

To date, the state (by and through its contracted companies) is knee-deep in audits for behavioral health providers.  Also, dentists, speech therapist (if you don’t group speech therapists in with behavioral health), and durable medical equipment providers have just been added to audit list.

According to the February 2013 NC Medicaid Bulletin, starting at the end of February/beginning of March, HMS (our 2nd RAC vendor) will perform post-pay audits on:

  • inpatient hospital claims;
  • outpatient hospital claims;
  • long-term care claims;
  • laboratory claims;
  • x-ray claims; and
  • specialized outpatient therapy claims.

As it is only May, the full consequences of these audits that were only started at the end of February are not yet known.

From the actual beginning of a post-payment audit until the Tentative Notice of Overpayment, a few months pass.  Concurrently, the Carolinas Center of Medical Excellence (CCME) is conducting prepayment reviews.

From experience, once placed on prepayment review, a health care provider will try (to no avail) to remove itself from prepayment review for 6 months before having its Medicaid contract terminated.  Usually, at the point of termination, I get called.

So, I figure, with the time period lapse for both post and prepayment audits, I have until August-ish until the providers that provide the above-referenced services need me.

I guess my message is:

Do not think for one second that because your particular type of health care service has not been audited yet, that your particular type of service is safe. The audits are coming. It’s just a matter of when.

About kemanuel

Medicare and Medicaid Regulatory Compliance Litigator

Posted on May 8, 2013, in Dentistry Services, Division of Medical Assistance, Durable Medical Equipment, Health Care Providers and Services, Medicaid, Medicaid Audits, Mental Health, NC DHHS, North Carolina, Outpatient Behavioral Health, RAC Audits, Tentative Notices of Overpayment, Termination of Medicaid Contract and tagged , , , , , , , , , , , . Bookmark the permalink. Leave a comment.

Leave a Reply

%d bloggers like this: