Federal and state governments rely heavily on program integrity contractors to scrutinize and obtain financial recoveries from a wide array of healthcare providers. Responding successfully to these audits can be daunting, but effective legal representation is often critical to a fair, cost-effective, and principled result. Morgan Lewis attorneys have experience assisting our healthcare clients in responding to a wide variety of Medicare and Medicaid program integrity contractor audits and reviews, including audits and inspections conducted by the following:
- Zone Program Integrity Contractors (ZPICs)
- Recovery Audit Contractors (RACs)
- Program Safeguard Contractors (PSC)
- Carrier and Fiscal Intermediary (Part A/B MAC) Program Integrity Units
- State Medicaid integrity Contractors (MICs) and Medicaid Program Audits
- State and Health and Human Services Office of Inspector General (OIG) Audits and Inspections
Our team works closely with clients to formulate strategic responses to program integrity audits and reviews. We offer a deep understanding of the legal authority of each type of contractor, the limitations on medical record requests and the use of statistical sampling and extrapolation, and other legal defenses associated with program integrity reviews. We help our clients prepare effective and credible responses to audit requests, often working closely with the client's clinical and billing/coding staff to provide efficient and cost-effective services. Under certain circumstances and where appropriate, we also engage specialty billing and/or medical record/clinical consultants, as well as statisticians, with expertise in the particular service area affected by the audit. We regularly assist clients in preparing appropriate written responses to reduce the potential for large overpayment findings and demands. We also assist with corrective action plans, remedial measures, and compliance program enhancements that advance our clients' interests in connection with these program integrity audits and reviews.
Our team regularly assists clients with appeals of overpayment determinations, redeterminations, and reconsiderations; Administrative Law Judge and Departmental Appeals Board hearings and appeals; and appeals before state adjudicatory bodies. Not all audits and reviews proceed without controversy. Issues of program integrity contractor responsiveness and scope of contractor authority arise from time to time. Judgment and experience are important in those instances where it is necessary to reach out to government program officials (e.g., the Medicare or Medicaid Program Integrity Group at CMS) to address concerns about how an audit or review may be proceeding with a program integrity contractor. Our team includes former OIG and DOJ healthcare fraud prosecutors who can assist with the strategic assessment of potential referrals and coordination with law enforcement by the Medicare and Medicaid program integrity contractors.
Our breadth of experience in connection with these types of audits and appeals includes responding to program integrity contractor and OIG audits for hospitals, DME suppliers, rehabilitation and post-acute providers, home health, physician practices, community mental health centers, hospice, dialysis clinics, and retail and specialty pharmacies. Morgan Lewis can help you prepare for, respond to, and defend against program integrity contractor audits and reviews.