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Medicaid audits can upend the day-to-day operations of a healthcare provider. A sudden demand for records, aggressive repayment claims, and the looming threat of penalties often leave practices scrambling. You need a Medicaid audit defense lawyer with proven experience responding to complex audits and challenging Medicaid audit findings.
Lowther | Walker serves healthcare providers nationwide with Medicaid audit defense services..
Our Medicaid attorneys have decades of combined experience guiding physicians, clinics, hospitals, and other providers through audits, appeals, and enforcement actions.
We are ready to help protect you, your reputation, and your healthcare business against repayment demands, civil penalties, and potential fraud allegations.
No-obligation. Fully confidential.
Call Us Today: (404) 496-4052
Investigation terminated; no prosecution. DOJ notified our client, the CEO of a major hospital network, that he was the target of a multi-million-dollar healthcare fraud investigation related to “Medicare upcoding” that the FBI and HHS-OIG […]
The FBI and the HHS-OIG investigated our client for Health Care Fraud based on the client’s submitting over $7 million in alleged false claims to Medicare. The Government indicted our client on Conspiracy to commit […]
HHS-OIG investigated our client for Healthcare Fraud and Aggravated Identity Theft based on the client’s allegedly participating in a “telemedicine” kickback scheme that defrauded Medicare of approximately $30 million in reimbursements for not-medically-necessary durable medical […]
A private insurance company discovered that our client, a dentist, fraudulently billed it, various other insurance companies, and federal health care benefit programs for approximately $400,000 of services that our client did not provide. We […]
The Department of Justice’s Criminal Division, Fraud Section charged our client and nine other individuals in a $1.4 Billion health care fraud, wire fraud, and money laundering conspiracy (the largest health care fraud case that […]
Investigation terminated; no prosecution. DOJ notified our client, the CEO of a major hospital network, that he was the target of a multi-million-dollar healthcare fraud investigation related to “Medicare upcoding” that the FBI and HHS-OIG […]
The FBI and the HHS-OIG investigated our client for Health Care Fraud based on the client’s submitting over $7 million in alleged false claims to Medicare. The Government indicted our client on Conspiracy to commit […]
HHS-OIG investigated our client for Healthcare Fraud and Aggravated Identity Theft based on the client’s allegedly participating in a “telemedicine” kickback scheme that defrauded Medicare of approximately $30 million in reimbursements for not-medically-necessary durable medical […]
A private insurance company discovered that our client, a dentist, fraudulently billed it, various other insurance companies, and federal health care benefit programs for approximately $400,000 of services that our client did not provide. We […]
The Department of Justice’s Criminal Division, Fraud Section charged our client and nine other individuals in a $1.4 Billion health care fraud, wire fraud, and money laundering conspiracy (the largest health care fraud case that […]
A Medicaid audit is not a routine compliance check. The audit is a formal investigation into whether a provider’s claims were billed properly and supported by patient records. These reviews may be initiated by:
Auditors are often motivated to find overpayments, which means their reviews may be conducted aggressively and without regard to the strain it places on your practice.
While every audit is unique, providers typically encounter the following sequence:
The process starts when you receive formal notification and document requests. The notice will come from either the state Medicaid agency, third-party audit firms, or a federal agency such as the Department of Health and Human Services.
Auditors begin by analyzing billing data and patient files. They will review your documentation for red flags, including a high rate of claims for new patients and referrals, or a high volume of claims re-submissions.
The auditors then produce a preliminary report highlighting their findings, which may allege overpayments or improper billing. The Medicaid Integrity Coordinators will present a draft report, which is then shared with the state Medicaid agency representatives, who ensure the following of Medicaid policies.
After the auditors produce their report, you’ll have 30 days to submit supporting documentation or challenge findings.
After receiving your documentation and analyzing the challenges to the auditor’s findings, the Medicaid Integrity Contractors (MICs) will present their final determination. Potential audit results can include payment suspensions and requests for recoupment of overpayments, as well as fines if recoupment payment timeframes are not met.
If a Medicaid audit results in an overpayment demand or violation notice, providers have the right to appeal through a structured process. This typically begins with filing a timely request for reconsideration, followed by an administrative review where additional documentation and arguments can be submitted. In some cases, the matter may proceed to a hearing before an administrative law judge, and if necessary, further appeals can be made in state or federal court. Meeting deadlines and presenting strong evidence are critical to success.
Working with an experienced Medicaid audit lawyer from Lowther | Walker during this process is invaluable. Our attorneys understand the technical rules audit appeals, prepare persuasive evidence, and negotiate with agencies to reduce penalties or repayment amounts.
Take the following steps as soon as possible after receiving notice of a Medicaid audit:
1. Engage legal counsel immediately
The first hours after receiving an audit notice are crucial. Having an attorney step in right away ensures auditors communicate with counsel, not directly with staff, reducing the risk of accidental admissions or incomplete responses. Legal guidance also helps establish a defense strategy before deadlines tighten.
2. Organize documentation
Auditors often demand vast amounts of documentation with little time to respond. Our team carefully organizes billing records, treatment notes, and compliance policies to identify inconsistencies before anything is submitted. This proactive review allows us to correct errors, strengthen your case, and protect against unnecessary penalties.
3. Review Proactive Resolution Options
In some cases, acknowledging and disclosing minor errors early can demonstrate good faith and reduce penalties. Skilled attorneys know when voluntary disclosure works to your advantage and when it could backfire. We develop tailored strategies to mitigate risk, safeguard your reputation, and position your practice for a favorable outcome.
Healthcare organizations choose Lowther | Walker for our proven record of defending providers during Medicaid audits and related enforcement actions. Our attorneys have spent years navigating complex audits conducted by state agencies and federal contractors, developing strategies that protect providers from repayment demands, civil penalties, and fraud allegations.
Medicaid programs are administered at the state level, but audits are often carried out by federal contractors with authority across multiple jurisdictions. Our firm represents providers in all 50 states, whether you operate a small local practice or a multi-state healthcare system, ensuring consistent, informed defense wherever you are located.
Unlike general healthcare law firms, our attorneys concentrate specifically on audits, compliance reviews, and fraud investigations. This exclusive focus allows us to stay ahead of regulatory changes, understand the strategies used by auditors, and craft defenses grounded in Medicaid law, coding requirements, and enforcement trends.
The most effective defenses begin the moment an audit notice arrives. We immediately step in to manage communications with auditors, analyze the scope of requests, and identify vulnerabilities in documentation. By acting quickly, we reduce the chance of escalation, minimize disruption to your healthcare business operations, and protect long-term program participation.
When you’re facing a Medicaid audit with the potential for a criminal healthcare fraud referral, Lowther | Walker is the national leader for Medicaid audit defense. Our team is available 24/7 and can respond on short notice to consultation requests.
Book your free and confidential consultation online or call (404) 496-4052 to speak with a Medicaid audit defense lawyer today.
No-obligation. Fully confidential.
Call Us Today: (404) 496-4052
Yes. Audits can escalate to civil fines, exclusion from Medicaid programs, or even criminal prosecution if fraud is alleged.
Unlike Medicare audits, Medicaid audits are overseen by state Medicaid agencies and their contractors, often applying state-specific regulations in addition to federal rules. This means providers must navigate a patchwork of requirements, with variations in deadlines, appeals procedures, and enforcement priorities depending on the state conducting the audit.
Response timelines vary by state and contractor, but many Medicaid audit letters require submission of records within 10 to 30 days. Missing this deadline can lead to immediate adverse findings or default determinations. Retaining legal counsel ensures timely, accurate submissions that protect against unnecessary overpayment assessments.
No. Many Medicaid audits are “desk audits,” where contractors review records submitted electronically. However, high-risk providers or complex cases often involve onsite reviews, where auditors directly inspect patient charts, compliance procedures, and billing systems. These audits are more invasive and require careful legal oversight to prevent overreaching or misinterpretation.
