Medicaid Audit

Dedicated Federal Attorneys for Medicaid Audit Defense

Lynette Byrd
Attorney Lynette Byrd
Healthcare Fraud Team Lead
Former Federal Prosecutor
Nick Oberheiden
Attorney Nick Oberheiden
Healthcare Fraud Team
Kevin M. Sheridan
Kevin M. Sheridan
Healthcare Fraud Team
Former FBI Special Agent
Wade McFaul
Wade McFaul
Healthcare Fraud Team
Former HHS-OIG Assistant Special Agent-in-Charge

For physicians, pharmacists, medical facility administrators, and owners of other healthcare businesses, facing a Medicaid audit can have serious consequences if you are unprepared. Our defense attorneys and former state and federal healthcare prosecutors bring their experience to representing clients in Medicaid audits and appeals.

Medicaid is unique among healthcare benefit programs in that it is subject to regulatory oversight and legal enforcement at both the state and federal levels. Agencies ranging from the U.S. Department of Justice (DOJ) and Centers for Medicare and Medicaid Services (CMS) – to Medicaid Fraud Control Units (MFCUs) and state attorney generals – investigate and prosecute cases of suspected Medicaid fraud. These investigations and prosecutions have the potential to lead to severe civil and criminal penalties.

But state and federal authorities have another tool to help fight Medicaid fraud and abuse as well. This is the Medicaid audit. Like the fee-for-service recovery audit program that exists for Medicare, CMS hires private contractors to audit and seek recoupments from providers suspected of overbilling Medicaid. These contractors perform a high volume of invasive audits, and they are financially incentivized to collect as much in Medicaid recoupments as possible.

Experienced Attorneys with a National Practice Focused on Healthcare Audits and Investigations

If your Medicaid billings are being audited you need to do everything possible to mitigate the risk of an adverse outcome. It is not unusual for a Medicaid audit to result in a substantial demand for recoupment. Failure to pay these recoupment demands can lead to fines, interest, and other penalties. Even worse yet is the potential for an adverse Medicaid audit determination to lead to a state or federal investigation. These investigations can result in civil or criminal litigation that brings even more financial penalties – and possible prison time.

There are a variety of ways that healthcare providers can mitigate their risk during a Medicaid audit. That is the first line of defense. But if it is too late to intervene in the audit process, rest assured that there are numerous potential grounds on which to appeal an unfavorable Medicaid audit determination. At Oberheiden, P.C., our attorneys have notable experience in matters involving state and federal healthcare audits and appeals. This includes experience as lead federal prosecutors responsible for overseeing healthcare fraud investigations, as well as experience in private practice helping clients across the country avoid liability and resolve their audits without the risk of facing civil or criminal charges.

Put our highly experienced team on your side

Dr. Nick Oberheiden
Dr. Nick Oberheiden



Lynette S. Byrd
Lynette S. Byrd

Former Assistant U.S. Attorney


Ellen Comley
Ellen Comley

Senior Counsel


Roger Bach
Roger Bach

Former Special Agent (OIG)

Steven Taylor
Steven Taylor

Healthcare Compliance Consultant

Susan Sage
Susan Sage

Healthcare Auditor

Skilled and Aggressive Legal Representation for Medicaid Audits

Due to the direct and indirect risks involved in facing a Medicaid audit, our firm takes an aggressive approach to representing healthcare providers during the audit process. Our goal is to obtain a favorable resolution as quickly as possible, and we focus on demonstrating our clients’ compliance with the goal to forestall recoupments or government inquiry. When Medicaid auditors are trying to find any possible grounds to justify a claim for recoupment, we will be standing by you so that both (i) the auditors operate within the confines of their mandate from CMS, and (ii) you are not falsely accused of overbilling the Medicaid system.

The types of issues we routinely encounter and address on behalf of healthcare providers in Medicaid audits include:

  • Allegations of intentional and unintentional coding errors
  • Allegations of billing Medicaid for services, supplies, and equipment that were not medically necessary
  • Allegations of supplying or relying on fraudulent physician certifications
  • Allegations of drug diversion, pharmaceutical fraud, and other forms of prescription drug fraud
  • Allegations of offering and accepting illegal kickbacks and other forms of remuneration
  • Medicaid auditors exceeding the scope of their authority during audits and investigations
  • Medicaid auditors relying on outdated billing regulations and faulty auditing methodologies
  • Medicaid auditors misinterpreting billing regulations and providers’ billing records
  • Medicaid auditors reaching flawed conclusions based on the records and evidence available
  • Medicaid auditors rushing to judgment without considering all of the relevant evidence and related factors

During Medicaid audits, we challenge the auditors’ methods and conclusions from all angles – seeking not only to demonstrate our client’s compliance, but also to call out flaws in the auditing process. Mistakes during the auditing process happen, and our healthcare fraud defense attorneys have the knowledge and insights to address unjust recoupment demands and misguided investigations and prosecutions.

Why Do Clients Trust Oberheiden, P.C.?

Reputations aren’t built overnight, and clients facing federal investigations wisely refrain from extending their trust to just anyone. The following are a few of the reasons why clients trust the experienced attorneys at Oberheiden, P.C..

1. Our Federal Experience

We offer our clients notable experience working in the federal system. We have tried or supervised many federal cases, and our top four trial lawyers have suffered a grand total of one jury trial loss among them. Nevertheless, if all you need is guidance on how to comply with federal regulations so that you don’t become a target of a federal investigation, we can provide you with the necessary guidance.

2. Our Unique Perspective

A federal investigation looks very different from the prosecutor’s table than it does from the defendant’s table. Several of our attorneys enjoyed distinguished careers as federal prosecutors before they joined us, and that gives us the ability to anticipate the strategies that will be employed by the government against our clients.

3. Our Successful Results

Our firm’s history is replete with dismissed indictments, avoided grand jury proceedings, saved professional licenses, closed investigations, victorious jury trials – and elated clients. A great many of our cases have been closed with no civil or criminal liability assessed against our client. These successful case outcomes involve not only the Department of Justice but many other federal agencies as well.

4. Our Teamwork

The federal government possesses vast resources, and when it launches an investigation into a matter of any consequence it assigns a team of investigators, federal agents, and prosecutors to the case. You are not likely to be able to deal with these people effectively without a working team of your own. Oberheiden, P.C., can supply a team that will work together seamlessly to maximize your best interests.

5. Our Commitment

We know from years of professional experience exactly the toll that an intrusive federal investigation can take on you, your family, and your business. We are passionate about protecting our clients’ interests from reckless and irresponsible government meddling and overreaching. Nobody pushes our clients around.

Answers to Frequently-Asked Questions (FAQs) about Medicaid Audits

Q: Why are my healthcare company’s Medicaid billings being audited?


Each year, Medicaid pays billions of dollars in incorrect, false and fraudulent claims. While many of these claims are the result of simple human error during routine billings by law-abiding healthcare providers, Medicaid also suffers substantial losses due to comprehensive fraud schemes involving organized crime.

As crime organizations targeting Medicaid have become more sophisticated, their fraudulent schemes increasingly mirror the practices of legitimate providers. As a result, state and federal authorities are facing increasing challenges in differentiating between fraud artists and quality healthcare organizations. This, in turn, has led to a comprehensive approach to combating Medicaid fraud, with authorities examining Medicaid billing data for apparent “anomalies” that have previously proven to be red flags for fraud.

The rise in Medicaid fraud has also led state and federal authorities to implement audit programs that rely on the services of third-party service providers. These third-party auditors (which are private companies that have won state and federal government contracts) get paid to uncover Medicaid fraud; and, in many cases, the more fraud they uncover, the more they get paid. As a result, many audit contractors are exhaustively targeting healthcare providers within their jurisdictions, and many are using data analytics software to review providers’ Medicaid billing records as a precursor to launching in-person investigations.

Q: What entities conduct Medicaid audits?


At the federal level, the contractors that CMS has engaged to audit Medicaid providers include Recovery Audit Contractors (RACs) and Audit Medicaid Integrity Contractors (Audit MICs). Audit MICs are subject to the oversight of CMS’s Medicaid Integrity Group; and, in most cases, there is one Audit MIC assigned to each state across the country. At the state level, various agencies may contract with independent auditors for the performance of Medicaid audits; and, in some cases, state-level authorities (such as Florida’s Bureau of Medicaid Program Integrity and New York’s Office of the Medicaid Inspector General) conduct audits directly as well.

Q: What is the difference between a Medicaid audit and a Medicaid fraud investigation?


While referred to as an “audit,” a Medicaid audit can be much more extensive and invasive than most providers might expect. In fact, in many cases, an audit can feel like a full-blown investigation. Multiple audit personnel may be involved, demanding thousands of pages of billing records, requesting to speak with employees from all departments of your business or practice, and even lodging accusations in an effort to compel the disclosure of more information that could lead to additional recoupments.

However, it is important to remember that an audit is not an investigation. Particularly in the case of an audit conducted by a private contractor, there are limits on their authority – and providers are not subject to the same legal obligations and standards that apply in federal and state cases. At Oberheiden, P.C., our experienced attorneys we make sure auditors stay within limits of their authority and we strategically use the structure of the Medicaid audit process to protect our clients to the greatest extent possible.

Q: What are the potential outcomes of a Medicaid audit?


Broadly speaking, there are two potential outcomes of a Medicaid audit: (i) a finding that your business or practice is liable for recoupments, or (ii) a finding of no liability. However, if your business or practice is found liable, this can lead to numerous other consequences. For example, an unfavorable audit determination may lead to:

  • Recoupment demands
  • Denial of pending Medicaid reimbursement claims
  • Prepayment review of future Medicaid reimbursement claims
  • Loss of Medicaid and Medicare program eligibility
  • Loss of assignment privileges
  • Civil or criminal state prosecution
  • Civil or criminal federal prosecution

State penalties for Medicaid fraud vary, but they are almost universally severe. For example, in Louisiana, providers can face civil penalties of up to $2,000 per false claim, and in Texas providers can face criminal fines and five years of imprisonment for each count of Medicaid fraud. At the federal level, prosecutors can seek civil or criminal penalties under the False Claims Act and various other laws – all with the potential to lead to crippling financial liability and long-term incarceration.

Q: Are Medicaid auditors targeting certain types of providers?


Ultimately, no. All providers are at risk for being audited, and contractors generally do not differentiate between types of providers when deciding whether to pursue an audit. That said, due to high levels of fraud within certain segments of the healthcare industry, certain types of providers have recently faced enhanced scrutiny from state and federal authorities. This includes dentists, compound pharmacies, home healthcare providers, and hospices, among others.

Q: How will your attorneys assist with my Medicaid audit?


Once you contact us, there are several steps our attorneys will take to assist with your Medicaid audit. Most immediately, we will make contact with the auditors and let them know that they need to deal directly with us during your investigation. This will help prevent them from soliciting information from your employees, including information that you may not be legally required to disclose.

We will also advise you and your key personnel on what your respective roles should be during the audit process. This may include serving as a single point of contact, maintaining electronic files as a records custodian, or acting as a subject matter expert on your company’s compliance policies and procedures. We will assist you in implementing a compliant “legal hold” as well; and, throughout the process, we will monitor the activities of the auditors in order to prevent them from exceeding their authority and, as is possible, from issuing flawed findings that could result in the unjustified imposition of liability.

Meet Our Team

Oberheiden, P.C. is law firm comprised of highly-experienced healthcare fraud defense attorneys who provide legal representation to clients across the nation. Many of our attorneys are former prosecutors with the DOJ and U.S. Attorney’s Office, and each team attorney is experienced in healthcare fraud-related matters. When you choose our firm, you will benefit from the collective experience of all of our attorneys. We will work collaboratively to craft a comprehensive defense strategy focused on securing the best possible outcome as quickly as possible.

As with all healthcare-related legal matters, when facing a Medicaid audit, early intervention can be critical to mitigating your risk throughout the process. We offer free initial case assessments; and, if you choose to work with us, we can take action immediately to take control of your Medicaid audit. To put our government side experience and understanding of Medicaid compliance law on your side, call or inquire online today.

Contact the Skilled Attorneys of Oberheiden, P.C. about Your Medicaid Audit

If you need legal representation for a Medicaid audit, we encourage you to contact us promptly to schedule your free initial case assessment. Our firm represents healthcare providers acrross the nation. To request an appointment with the healthcare fraud defense team at Oberheiden, P.C., please call 888-680-1745, or contact us online now.

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