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Medicaid Audits
Last Updated on: 31st March 2025, 04:19 pm
MEDICAID AUDITS
If you accept payments from Medicaid, you need to know that government auditors can review your claims at any time. Medicaid is a joint federal and state program, so both federal and state agencies may investigate your billing. Audits can be stressful, but if you understand what to expect, it becomes easier to protect yourself.
AS SEEN IN MANY STATES
Some states, like New York and Texas, are known for extra-tough enforcement. Other states may not audit as often, but they can still take swift action if they see possible fraud. This local twist is important—if the Medicaid office in your region suspects any wrongdoing, you’ll face serious consequences. You might even deal with the Office of Inspector General (OIG) or the Centers for Medicare & Medicaid Services (CMS).
WHY MEDICAID AUDITS HAPPEN
Medicaid pays for millions of claims every day. Because it involves taxpayer money, the government wants to ensure nobody abuses the system. Audits help the government see if providers—like doctors, clinics, or home care agencies—are following the rules. Audits can look for:
- Billing for services not actually provided
- Using the wrong codes to get higher payments
- Paying or accepting kickbacks for patient referrals
- Falsifying records to justify unnecessary treatments
If a reviewer decides your claims break the law, you could lose Medicaid funding, pay big fines, or in some cases face criminal charges. That can include prison time if a court decides you intended to cheat the system.
SPODEK LAW GROUP
WHAT MAKES US DIFFERENT
Spodek Law Group is a premier, nationwide federal defense law firm created by Todd Spodek. Our goal is to help you handle Medicaid audits and prevent them from becoming bigger problems—like investigations by the Department of Justice. We’ve seen how minor mistakes become major fraud allegations if you don’t fix them right away. We also know how local rules can change the entire strategy you use to defend yourself.
LEGAL PENALTIES AND WHAT YOU COULD FACE
When Medicaid suspects fraud, officials can use laws like the False Claims Act to demand triple the amount they claim you owed. They can also file criminal charges under the Anti-Kickback Statute, especially if there are illegal payments for referrals. If convicted, you could face large fines or even go to prison. You might lose your license or be barred from billing Medicaid altogether. That means losing your career, your reputation, and your livelihood.
WHAT HAPPENS DURING AN AUDIT
First, you’ll usually get a letter telling you what the auditors want to see. They may ask for charts, invoices, or other records. They compare your paperwork to your submitted claims to see if they match. If they find a pattern of overbilling, they could expand the audit, which means more time and stress for you. You can try to clarify any honest mistakes. Sometimes, if you can prove you didn’t intend to violate the rules, you’ll only face repayment. But if the auditors think you committed fraud, they might refer your case to law enforcement. Once that happens, you risk criminal charges.
HOW WE WOULD DEFEND YOU
At Spodek Law Group, we focus on facts and strategy. We would start by looking at the evidence the government has. If we find they got records without proper warrants, we argue those documents should be thrown out. If we see they applied the wrong law or used flawed billing data, we challenge their entire case. Every piece of evidence matters. Evidence that was illegally obtained might be inadmissible, which can weaken the prosecutor’s argument. A weaker argument means a greater chance for you to avoid criminal penalties.
We also work on negotiating. If the government’s case is strong, we might try to reach a deal to reduce charges or lower the fine. That can keep you out of jail or shorten your sentence. We push hard so you get the best result, given the facts on the ground.
SPOTLIGHT ON STATE-BY-STATE RULES
Because every state runs Medicaid differently, a mistake in California might not be a violation in Illinois. Some states require specific paperwork for home health visits, while others insist you use electronic systems that track staff hours. We make sure you follow the right rules for your area. If local rules are unclear, we cite any official guidance that supports you. That helps show you tried to comply in good faith.
TAKING ACTION: YOUR FIRST STEPS
When you get that first audit notice, take it seriously. Here’s what you should do:
- Stay organized: Gather all the records the auditors want. Missing or sloppy files make you look suspicious.
- Be careful what you say: Don’t speculate about errors. If you guess wrong, the government might think you’re lying.
- Seek help fast: Contact legal counsel before talking to investigators. You want someone who knows these rules to guide you.
If you wait too long, or fail to respond, that inaction can lead to harsher penalties. Silence makes auditors think you have something to hide. Think of it this way: once you’re under review, every word, email, or record can be used to build a case against you.
CASE RESULT EXAMPLES
We’ve handled tough audits for providers who thought they’d lose everything. One clinic in Florida was accused of billing for physical therapy that never happened. We showed that patients had incomplete progress notes because the staff didn’t know how to chart properly. By fixing the documentation problems, we got a smaller penalty and prevented a criminal referral. We can’t promise the same outcome for everyone, but we fight to reduce your risk and keep you in business.
DON’T IGNORE WARNINGS
If you’ve already been asked questions by CMS or the local Medicaid Fraud Control Unit, pay attention. Repeated billing errors might lead to a formal fraud investigation. Ignoring it doesn’t make it go away. Remember, if you find out you were overpaid by Medicaid and don’t report it within a certain time, you might face a false claim lawsuit. The government calls that a “reverse false claim,” and it’s no joke. The penalties can be huge.
REACH OUT TO US
We are Spodek Law Group, a nationwide federal defense law firm created by Todd Spodek. We are available if you need help. Our attorneys handle federal cases all over the USA, and we understand how local rules can impact Medicaid audits. We don’t make excuses. We take action. If you’re under audit, or think you may be soon, call us. Our job is to protect you, guide you, and fight for your future.
IMPORTANT DISCLAIMER
This article is for general information only and isn’t legal advice for your specific situation. Reading this doesn’t make us your attorneys. Each case is unique. If you want legal counsel, please contact us directly to discuss a formal agreement. Until you do, no attorney-client relationship exists.
CONTACT US, 24/7
We’re here when you’re ready to talk. Call now, or fill out our consultation form. We’ll be honest about your situation. We’ll push you to handle this issue properly. Our team believes in solutions, not excuses. Let’s protect your livelihood together.