Medicaid providers,

One of the best proactive measures to protect yourself from a Medicaid audit (all this goes for all types of providers… hospitals, psychiatrists, dentists…) is to conduct a self-audit. Without question. That way you can identify potential issues and fix them; thereby, in the long run, limiting your liability to a recoupment. But…TAKE HEED!

If you are going to self-audit, then fix any errors found.  Do not find errors and do nothing.  If you neglect to fix the errors found in a self-audit, then the penalty for not fixing a known error COULD be harsher than never knowing the errors.

Remember the fable, “The Hawk, the Kite, and the Pigeons?”

THE PIGEONS, terrified by the appearance of a Kite, called upon the Hawk to defend them. He at once consented. When they had admitted him into the cote, they found that he made more havoc and slew a larger number of them in a single day, than the Kite could possibly pounce upon in a whole year.

Moral:
Avoid a remedy that is worse than the disease.

I am definitely not comparing the Division of Medical Assistance (DMA) to a kite.  Maybe Aesop should have used two, equally, scary animals, but, in Aesop’s defense, I’m sure that the pigeons were terrified of the kite.

As for the pigeons…A Wisconsin-based medical clinic conducted an internal audit of 25 claims per physician. Good job! Be proactive!

However, the clinic discovered that 2 physicians were up-coding over 10% of their claims. As required, the clinic returned overpayments for those specific, up-coded claims.  So, obviously, whoever conducted this self-audit on the Wisconsin clinic informed the 2 physicians that their abhorrent billing practices were discovered and that they should immediate cease all up-coding, right? Or, at the very least, continued to monitor these 2 physicians’ billings, right?

Wrong.

The clinic conducted no more self-audits on those 2 physicians.  In fact, the clinic stopped conducting self-audits all together.  Furthermore, the clinic allowed those 2 physicians to continue billing without supervision. Ugh!

As expected, a former employee filed a whistleblower lawsuit against the clinic.  The lawsuit is pending, so we have no way of knowing the extent of whatever penalty this clinic may suffer. But, the warning is out! If a practice is billing Medicaid incorrectly, discovers the errors, and fails to take corrective action it COULD be considered fraud.

If you want to read the whole article click here.

The moral of the story? Avoid a remedy that is worse than the disease.