Home care agencies and long-term care providers are audited by state Medicaid program integrity offices, managed long-term care plans and other payors. In New York this includes audits by the Office of the Medicaid Inspector General (OMIG), and similar programs exist in New Jersey and Pennsylvania. Findings typically allege missing or deficient documentation, services not supported by the plan of care, or billing errors.

We engage at the first audit notice. We assemble and organize the records, respond to document requests, and review draft findings line by line. Where an auditor extrapolates a sample to a larger universe of claims, we examine the sampling and statistical method and challenge it when it is not sound.

If a final determination issues, we pursue administrative appeals and hearings and, where warranted, judicial review. We also negotiate repayment terms and settlements and advise on whether a self-disclosure is required for overpayments the provider identifies itself.

Managed long-term care plans audit under their own provider agreements, so we review the contract terms on audit procedures, appeal rights and recoupment, and pursue disputes through the plan's process or arbitration when needed.