United States

Are you ready for a Medicaid OIG post-payment integrity audit?


OIG recoups over $37 million in overpayments in fiscal year 2014
During fiscal year 2014, the Illinois Office of Inspector General (OIG) began expansion of its internal audit capabilities, completing 527 audits of providers participating in the Medicaid program. Almost one-third of these were long-term care facilities. These audits were developed using a DNA predictive modeling system.

Bureau of Medical Integrity (BMI)
The BMI performs post-payment compliance audits of providers, provider quality of care reviews and quality control reviews. In addition, the BMI conducts Medicaid eligibility quality control reviews and special project reviews. The BMI Audit Bureau performs audits on Medicaid providers to ensure compliance with the department’s policies. This includes long-term care facilities. In addition to audits performed by BMI staff, contractual CPA firms complete additional nursing home integrity audits.

Each year, the BMI selects 160 facilities for post-payment integrity audits. This is approximately one-sixth of the Medicaid-certified nursing homes in Illinois.

Will you be ready?
Your facility can be prepared for such an examination by following two key principles:

  • Be proactive. Reconcile your accounts receivable balances frequently. Errors made by posting payments from incorrect payer sources can create major headaches in the audit process. Keep a close watch on credit balances and document known overpayments.
  • Be prepared. The integrity audit process is designed to uncover overpayments to your facility and disregards cases where you were underpaid by the state. Have your records and documentation up to date before it is sent to the BMI Audit Bureau. You are given the opportunity to dispute the individual audit findings, but your responses must be detailed and well documented. If you discover an error in your favor, you are seldom allowed to offset what they might owe you against what they claim you owe them.

With proper preparation, you can be ready for a potential audit. If you are selected for an audit, it is recommended to involve your adviser and knowledgeable consultants in the audit and response process to help minimize any potential financial impact on your facility.


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