Medicaid Audits, Administrative Appeals, Administrative Hearings, & Litigation

The attorneys at DiRuzzo & Company represents health care providers in Medicaid audits, administrative appeals, administrative hearing before Administrative Law Judges, and subsequent Florida state court litigation with the Agency for Health Care Administration (“AHCA”). We represent health care providers at every stage of the process (i.e from start to finish) and have the skill set to take a case into court and on appeal if necessary.

Medicaid Overview

Medicaid is a cooperative federal-state program designed to assist states with the cost of providing health care to needy individuals. 42 U.S.C. § 1396 et seq. Benefits are administered through state agencies pursuant to a Medicaid program that has been submitted to and approved by the U.S. Department of Health and Human Services (“HHS”). The Centers for Medicare and Medicaid Services (“CMS”) is responsible for administering the Medicaid Act, including setting state guidelines and monitoring state compliance. Chapter 409 of the Florida Statutes and Title 59G, Florida Administrative Code, govern Medicaid in Florida and condition the receipt of Medicaid funds on the execution of a provider agreement under Fla. Stat. § 409.907.

Medicare Audits

The AHCA administers the Medicaid Program in Florida. In addition to processing claims, AHCA also conducts audits to determine possible fraud, abuse, overpayment, or recipient neglect. Fla. Stat. § 409.913(2). Medicaid audits are conducted on a random basis pursuant to Fla. Stat. § 409.913(2). Additionally, in Florida Medicaid fraud investigations, including the review of claims for evidence of fraud, are conducted by the Medicaid Fraud Control Unit (“MFCU”). Fla. Stat. § 409.913(4).

ACHA, when making a determination that an overpayment has occurred, prepares and issues audit reports to the health care providers showing the calculation of alleged overpayments. Fla. Stat. § 409.913(21). After an audit is conducted by ACHA, the audit report (with work papers), constitutes evidence of the overpayment to a health care provider. Fla. Stat. § 409.913(22).

Administrative Appeal

A health care provider can request an administrative hearing pursuant to Fla. Stat., Chapter 120. Fla. Stat. § 409.913(31). The Chapter 120 hearing is generally conducted within 90 days following assignment of an administrative law judge (“ALJ”) by Florida’s Division of Administrative Hearings (“DOAH”). Fla. Stat. § 120.57(1) provides for a full evidentiary hearing before an ALJ (to resolve disputed factual issues) when an AHCA’s determinations affect a health care provider’s substantial interests (such as the termination of a provider agreement under Fla. Stat. § 409.907).

Judicial Review

If an ALJ issues an adverse decision to a health care provider Fla. Stat. § 120.68 provides for judicial review. Upon the timely filing of a notice of appeal (in accordance with the Florida Rules of Appellate Procedure), the litigation can be brought in either the Florida District Court of Appeal where the health care provider maintains his/her/its business headquarters or the First District Court of Appeal in Tallahassee (where AHCA is located). Fla. Stat. § 120.68(2)(a). The Florida Supreme Court reviews adverse decisions of District Courts of Appeals.