Medi-Cal Audit Support and Appeals

Federally Qualified Health Centers (FQHCs) and Rural Health Clinics (RHCs) depend on accurate Medi-Cal ratesetting and reconciliation to ensure fair reimbursement. Athene Law provides comprehensive support at every stage of this process—from cost reporting to audit support, administrative appeals, and litigation in court. 

We offer strategic, hands-on guidance to help clinics secure a PPS rate that reflects the true allowable cost of delivering care. Our experience spans a wide range of providers, including public and private clinics, hospital-based and independent facilities, and FQHCs, FQHC look-alikes, and RHCs.

Capabilities

Our representation of FQHCs and RHCs in Medi-Cal reimbursement issues has included:

•     Coordinating with DHCS to ensure all allowable costs are included in the PPS ratesetting
• Challenging the denial of change in scope-of-service requests
• Challenging the elimination of “excessive” costs, where DHCS applies informal ratios or unsupported benchmarks
• Defending against reductions for untimely wraparound claims

• Ensuring proper allocation of overhead costs for provider-based clinics, particularly when DHCS questions the benefit to the clinic or claims duplicative cost reporting
• Contesting the improper application, or refusal to apply the related party doctrine
• Advocating for the appropriate counting of visits, including challenges to disallowances tied to productivity standards, group therapy visit limits, or classification of visit types
• Opposing disallowances based on inconsistent reporting methodologies between ratesetting and non-ratesetting years
• Identifying and correcting errors in tentative PPS rate calculations