Health Care Audits

We represent providers and practices nationwide during Medicare audits, Medicaid audits and third-party payor audits. Our team of audit attorneys has extensive experience in Medicare audits, including ZPIC, RAC, and Safeguard (PSC) audits. Our team of health care audit attorneys is dedicated to helping providers defend their claims during audits, recovery action and appeals.

Receiving an audit letter or any request for information from the government can be intimidating and confusing. The first and most important step is to read the audit letter thoroughly. It is important to determine which government entity is requesting the information. Centers for Medicare and Medicaid Services (CMS) uses a balanced approach to prevent improper payments and to identify and recoup improper payments that have already been issued. Several government agencies and government contractors are tasked with health care fraud detection and prevention.  Each government agency attacks health care fraud through a different avenue. Some government agencies simply ask for additional information or documentation for specific claims. Sometimes, government agencies or contractors will identify a certain area of risk within a medical specialty or procedure and will conduct “spot checks” of random samples of claims. Other agencies will conduct audits and investigations when there is a suspicion of health care fraud by a specific health care provider.

Medicare Administrative Contractors (MAC) Audit

Audit letters can be received from a variety of government entities. Some audit letters come directly from the Medicare Administrative Contractors (MACs). MACs handle fee-for-service operations for the Medicare program within their geographic region. Commonly, MACs will perform “Medical Review” of fee-for-service claims. Medical providers will receive a request for additional documentation for certain medical services or medical equipment. This information must justify the services or equipment that was provided to the patient. Read more about MAC audits, investigations and appeals process

Recovery Auditor Contractors (RAC) Audit

Audit letters or requests for information can also be received from Recovery Auditor Contractors (RAC). Recovery Auditors identify and correct underpayments and overpayments. Read more about RAC audits and investigations.

Zone Program Integrity Contractors (ZPIC) Audit

Sometimes, audit work can be completed by Zone Program Integrity Contractors (ZPICs). ZPICs assist with appeal and audit backlogs as well as other special projects. ZPICs identify cases of suspected fraud and take corrective actions. Read more about ZPIC audits and investigations

Comprehensive Error Rate Testing (CERT) Audit

Finally, CMS utilizes Comprehensive Error Rate Testing (CERT) contractors to statistically identify improper payment rates. CERTs collect documentation and perform reviews on random samples of fee-for-service claims. Read more about CERT audits and investigations

What to Do If You Receive an Audit Letter

Physicians and other health care providers shouldn’t take an audit letter lightly. Health care providers should inform their staff about the possibility of government audits and should develop a plan for receiving and responding to these requests. An important part of preparation is to identify key staff members who would be likely to receive an audit letter. Many times, the audit letter will be sent in the mail or may be hand delivered. As a result, billing representatives and receptionists should be made aware of this possibility and should be trained to notify the practice managers immediately when such a request is received.

A response is mandatory and must be filed within a certain period of time. The period of time to respond varies depending on which government entity is requesting the information and for what purpose. A timely response to a government audit letter is vital, but the response should not be rushed and should be prepared by a qualified health care attorney.  Health care providers should consider what is being requested and why the information is being requested. Sometimes, this may be difficult to determine. Physicians and health care providers should be aware of the risks of exposure in releasing incorrect or damaging information to government agencies.

Before responding to a request that is unfamiliar, health care providers should consult with a health care attorney to confirm what is being requested, who is requesting the information, and what information should be submitted. Because government audit letters are time sensitive, it is advantageous for health care providers to establish a relationship with a competent health care law attorney before an audit letter is received. Forming this relationship will allow the physician or health care provider to work with their legal counsel to prepare a timely and thorough response to an audit letter without inadvertently releasing damaging information in the process.