00011_RT8By George F. Indest III, J.D., M.P.A., LL.M., Board Certified by The Florida Bar in Health Law

We have recently been contacted by several pediatric practices that were subject to Medicaid audits. In several cases, the pediatricians received the final audit reports (FARs) stating that they owed Medicaid refunds, because of overbillings, in the tens of thousands of dollars.

With such demands for repayment of the alleged overpayments also come:

  1. Fines;
2. Penalties;
3. Requirements to sign agreements to refrain from such practices in the future;
4. Requirements to have personnel retrained; and
5. The specter of future audits.

In many cases, Medicare and Medicaid auditors may swiftly review supporting medical records and overlook key components that support the level of services (or CPT codes) that were billed, erroneously downgrading the code or disallowing the charge completely. Other times the pediatric or medical practice may have only provided partial records and have left out some key records that would support the codes billed.

Challenging the Determination.

Unfortunately, after receipt of the FAR, the only hope of challenging the determination would come by filing a written request or petition for a formal hearing in, specifically, a Medicaid case. In Medicare cases, other interim reviews or appeals are available.

If you have additional records you failed to provide, or if after a thorough review of the records you did provide show that all of the elements of a CPT code you billed (e.g., 99204 or 99205) were documented, then we recommend that you immediately retain the services of a board certified health lawyer experienced with Medicare and Medicaid audits to file a petition for you. Be sure a written request or petition for a formal hearing is filed within the time stated in the letter you receive, even if you must retain an attorney afterwards. Remember that the request must be in writing and must be received by the agency at the address specified before the date in the letter has passed.

You can always work out a settlement agreement, repayment agreement, or agreement for a different resolution of the situation. What you can’t do is to go back and get back your hearing rights after they have expired.

Steps to Take if you Receive Notice of an Audit.

What you should do immediately upon receiving notice of an audit:

 1. Retain the services of a board certified health lawyer who is experienced with such audits.

 2.  In a timely manner, provide all relevant documents pertaining to the audit, properly labeled and pages numbered (note:  in many instances, this may include more than just the minimum documents the audit requested).

 3. Watch for any interim, initial or preliminary audit reports (PARs), and be prepared to rebut it in detail if it requests a refund.

 4. If you receive a FAR demanding a repayment, be prepared to hire a board certified health lawyer who is experienced with such audits, if you have not already done so.

 5. If you disagree with the findings in the FAR, be sure the agency receives your request for a formal hearing to challenge the determination, prior to the date given in the FAR or demand letter.

For additional details, pointers and tips on this subject you may click here to read the prior blog we have published.

For information, details, pointers and tips on the subject of Medicare audits, you may click here to read the prior blog we have published on this.


Do you know what to do if you are the target of a Medicaid audit? Did you know about requesting a hearing on the final audit report results? Please leave any thoughtful comments below.

Contact Health Law Attorneys Experienced with Medicare and Medicaid Cases.

Attorneys with The Health Law Firm represent physicians, medical groups, nursing homes, home health agencies, pharmacies, hospitals and other healthcare providers and institutions in Medicare and Medicaid investigations, audits, recovery actions and termination from the Medicare or Medicaid Program. We also handle Medicare audits, ZPIC audits and RAC audits throughout Florida and across the U.S.

Our attorneys also represent health care professionals and health facilities in qui tam or whistleblower cases both in defending such claims and in bringing such claims. We have developed relationships with recognized experts in health care accounting, health care financing, utilization review, medical review, filling, coding, and other services that assist us in such matters. We have represented doctors, nurses and others as relators in bringing qui tam or whistleblower cases, as well.

To contact The Health Law Firm, please call (407) 331-6620 or (850) 439-1001 and visit our website at www.TheHealthLawFirm.com.

About the Author: George F. Indest III, J.D., M.P.A., LL.M., is Board Certified by The Florida Bar in Health Law. He is the President and Managing Partner of The Health Law Firm, which has a national practice. Its main office is in the Orlando, Florida, area. www.TheHealthLawFirm.com The Health Law Firm, 1101 Douglas Ave., Altamonte Springs, FL 32714, Phone: (407) 331-6620.

The Health Law Firm” is a registered fictitious business name of George F. Indest III, P.A. – The Health Law Firm, a Florida professional service corporation, since 1999.

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