'I don't know' won't cut it

Thursday, April 30, 2009

Q. What can HME providers expect when it comes to audits and recoupments by state Medicaid programs?

A. The Bush administration intentionally squeezed state Medicaid budgets. Despite its every effort, it was only able to implement modest reductions in Medicaid spending. Still, those reductions resulted in millions of dollars in savings.

The Bush Administration then decided that the best way to save additional money in the Medicaid program was to create incentives for states to recoup money by identifying instances of fraud and abuse. Consequently, Congress enacted the Deficit Reduction Act (DRA), which creates a number of incentives such as additional funding for states to aggressively pursue providers who engage in fraud and abuse. This means that retrospective audits and recoupments are very attractive to regulators and, since the incentives are so powerful, may be more difficult than usual for providers to resolve reasonably.

Providers must, therefore, do everything they can to make sure their noses are clean.

First, providers have an obligation to be vigilant - to check up on or monitor on a regular basis to make certain that applicable requirements are being met. If auditors can show that providers either knew about or should have known about a pattern of conduct, the audit results may have serious consequences. Saying “I didn’t know” or having good intentions isn’t enough. There should be nothing that providers should have known about, but did not.

Another way to help ensure positive results is to implement and/or properly maintain fraud and abuse corporate compliance plans so that providers are able to demonstrate in concrete ways that they were monitoring on a regular basis.

Elizabeth Hogue is a private practice attorney. Reach her at 877-871-4062 or elizabethhogue@elizabethhogue.net.