Florida health care providers that provide services to Medicaid recipients are likely, at some point, to receive an audit of their claims submitted to the Medicaid program for reimbursement. Some providers will, for any number of reasons, receive a preliminary audit report detailing the Agency for Health Care Administration’s (Agency) findings as well as setting forth the administrative options of the provider at that point, including the possibility of submiting additional information/documents, or accepting the findings and entering into a repayment of the overpayment, or waiting for the Agency to issue the Final Audit Report (FAR). However, the submission of additional documentation or waiting for the issuance of the FAR will waive the provider’s opportunity to have any monetary sanctions removed such as the statuary 20% sanction of the established overpayment amount.
Should the Provider submit additional documentation, the Agency analyst will review the additional documents received and will issue a Final Audit Report. The FAR will contain findings of the Agency as to why certain claims are denied and not reimbursable (such as medical reasonableness, incomplete documentation, missing signature, provider eligibility etc.) as well as establishing what the dollar amount of the overpayment (actual or extrapolated), costs and monetary sanctions to be imposed (20% of the overpayment amount and possible $2,500.00 for failure to provide complete records among other possible sanctions).
The Provider upon receipt of the FAR should contact an experience health care attorney who has handled administrative cases with the Agency. It is important that the Provider, either with the assistance of counsel or without an attorney, timley respond to the FAR within twenty-one (21) days of receiving same in order to preserve the Provider’s administrative rights and the opportunity to challenge the FAR, its findings and the overpayment amount. Mr. Rafael (Ralph) Gaitan, Esq., is experienced in challenging Agency Final Audit Reports for various different types of health care providers, including physician, physician groups, health care clinics, home health agencies, behavior analyst companies, hospices, etc. Mr. Gaitan can be reached at (786) 440-8115 or via email to firstname.lastname@example.org should you require additional information or should you require assistance in challenging a FAR.