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Medicaid Audits in Florida

June 17, 2022
Est read time: 3 minutes


Today, the medical audit has become crucial to provide efficient and accurate documentation for healthcare organizations. Through medical auditing, including self-audits, it becomes possible to identify areas that healthcare providers should improve upon. The Agency for Health Care Administration or AHCA conducts its own audits of Medicaid Providers in Florida.

The Nature of Medical Auditing

In the finance world, auditing is one of the most commonly used procedures that verifies and validates the company records to determine whether or not they’re accurate and complete. Similarly, medical auditing refers to a dedicated process to review medical records. The idea is to ensure that the medical equipment, healthcare facilities, and doctors operating in a clinic or hospital setting follow standard medical regulations and provide the best services.

Mechanics and Details of the Medicaid Audit

When it comes to the Medicaid audit, healthcare providers receive an official letter or communication from Agency for Health Care Administration notifying the nature and requirement of the audit. Typically, AHCA provides a list of patients/clients or requests samples from the list to the healthcare providers.

 Although it depends on the practice size and operational capacity, the sample list can contain 30 to 150 names of the patients. On average, routine medical requests involve 30 to 50 records of the patients. Typically, the audit letter from the AHCA comes with a detailed questionnaire and a dedicated form.  AHCA will also frequently follow up with additional requests for related information.  

Response to the Medicaid Audit

Essentially, you have to fill out the Completeness of Records Certificate form and Medicaid Provider Questionnaire.  After that, healthcare providers have to send back the copies of the completed form and questionnaire with the sampled records of the patients/clients.  It is crucial to understand that if you decide to include supplemental or additional copies of patient/client records, auditors can use them against you.

The Process of the Medicaid Audit

As per Florida Agency for Health Care Administration, you will have a brief window of time to provide the required documents. You should review any AHCA letter carefully and take into consideration:

  • Any Deadlines

Once you receive the official Medicaid audit notice, time is of utmost importance. Record the date in your calendar to send the patients’ records before the due date.  If you cannot locate all of the records by the deadline, it is helpful to have legal assistance.  

  • Review Claims 

Review the submitted copies of the claims and determine the amount paid by Medicaid on audited patients.  Make a comparative analysis of Medicaid records and review information to find any inconsistencies or errors that may come into the spotlight during the AHCA review.  A provider may also conduct a self-audit.  The self-audit should cover only those records and issues that AHCA has identified.  If you discover additional issues in the billing, consult an experience attorney.  

  • Separate Potential Issues

If you believe a specific patient record would create a problem, you should prepare a realistic explanation and then submit it along with that patient’s file.

  • Send Relevant Information

You should include the X-Rays or use compact discs or USB drives to send information referenced on  the Completeness of Records Certification.

  • Fill Out Questionnaire Completely

When it comes to filling out Medicaid Provider Questionnaire, be sure to not leave out any details related to patients’ records. If you use complex abbreviations, make sure to note their meaning and how it ties together with the patients’ records.

  • Get Professional Help

One of the main steps healthcare providers should take is to reach out to an experienced healthcare attorney to develop a strategy for responding to the AHCA letter.

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