Audit Defense & Remediation

Medicaid Audits Are On The Rise

Your chance of being flagged for a CMS Medicaid audit is greater than ever. Why? Due to the post-pandemic audit holds, Medicaid recoupments are seriously down, and there are still many misunderstandings regarding allowed practiced during the COVID restriction.  So, the Medicaid Integrity Program (MIP) and Medicaid Fraud Control Unit are moving into high gear.  Recently, we’ve seen attempts to disallow as much as 87% of prior payouts. Even if you believe your Medicaid billing is up to snuff, all it takes is one mistake or accusation by a disgruntled employee to open the door for auditors to start poking around. The good news is, there are ways for you to protect your practice even if you are targeted for a Medicaid audit. 

APEX Healthcare excels in risk management, handling complex MCO audit cases, appeals and even Department of Justice investigations. To effectively address audit findings and mitigate potential risks, we’ve established a 6-Point Audit Remediation Plan: 

1. Understand Your Audit Findings:

• Thorough Review each audit finding or allegation to understanding the nature of the issue and prevalence outside of the sample group.

• Seek Clarification from the auditor to determine the validity of their extrapolation methods.

  
  

2. Prioritize Your Responses:

• Risk Assessment: Evaluate the severity and likelihood of each finding, prioritizing those with the highest potential impact or risk. 

• Focus on Critical Areas: Concentrate resources on addressing the most critical findings first, ensuring that the most significant risks are mitigated

  
  

3. Develop an Action Plan:

• Assign Responsibility: Clearly assign responsibility for addressing each finding, ensuring accountability and ownership.

• Set Timelines: Establish realistic timelines for addressing each finding, including milestones to track progress.

• Document Actions: Document all actions taken to address the findings, including the rationale for each action and the expected outcome.

  
  

4. Leverage Technology:

• Automation: Explore the use of technology to automate processes and improve compliance, reducing the risk of future errors.

  
  

• Data Analysis: Use data analytics to identify trends and patterns in audit findings, enabling proactive risk mitigation. 

  
  

5. Foster a Culture of Continuous Improvement:

• Regular Monitoring: Establish a system for regularly monitoring the effectiveness of implemented mitigation measures, ensuring that risks remain under control.

• Review and Improvement: Regularly review audit findings and mitigation efforts to identify areas for improvement and continuous learning. 

• Training and Education: Provide training and education to employees on relevant policies, procedures, and compliance requirements. 

• Communicate and Report: Ensure clear communication of audit findings and mitigation actions to all relevant stakeholders, including management and employees.

  
  

6. Monitor Progress and Review Effectiveness

• Finally, regular monitoring and review are essential to ensure that your mitigation strategies are effective. This involves tracking progress against your action plan, reviewing the effectiveness of implemented changes, and adapting your strategy as needed.

• Here, you can deploy

Making Opportunities out of Challenges

Apex becomes your outsourced risk management department. We proactively identify potential exposures and create a corrective action plan to strengthen your practice.  The 6-Step plan gives us everything we need to effectively avoid negative impacts, challenge findings, extrapolation methods, disallowances and create a culture of improvement. By implementing these mitigation strategies, you can transform your audit results, adding value to your organization. If you’re facing any type of adverse actions, audit or investigation, we can help.

Contact us for a complimentary consultation and case assessment:   

www.info@ApexHealthAdvisory.com                               (888) 536-7828