What Happens During a Medicare/Medicaid Audit of a Medical Provider?

 Posted on June 15, 2021 in Medical License Defense

Most medical providers, including doctor’s offices, hospitals, pharmacies, and other types of medical professionals, provide services to patients and accept payments through Medicare or Medicaid. Providers must meet a variety of requirements when doing so, and the Centers for Medicare and Medicaid Services (CMS) is tasked with ensuring that providers are in compliance. CMS may conduct audits of providers based on billing irregularities, issues related to record-keeping, or other concerns about potential noncompliance. During these types of audits, providers will want to understand the process that will be followed and the requirements they must meet. Failure to comply with CMS requirements or cooperate during an audit could result in the provider being excluded from providing services through Medicare or Medicaid.

Steps Followed in a CMS Audit

The Medicare/Medicaid audit process has four phases:

1. Engagement and universe submission - Auditors will notify a provider of an audit and send an engagement letter that identifies the information that will be requested. This information will take the form of “universes,” which consist of data sets from a health plan, including Part C Organization Determinations, Appeals, and Grievances (ODAG) and Part D Coverage Determinations, Appeals, and Grievances (CDAG). After the provider submits the requested universes, auditors will assess the data provided and determine whether any other information is necessary. This phase will last six weeks.

2. Field work by auditors - Auditors will conduct webinar audits and evaluate sample data from the submitted universes. If any instances of noncompliance are identified, the provider will be asked to provide a root cause analysis and an impact analysis. Auditors may also conduct an on-site Compliance Program Effectiveness (CPE) audit. This phase will last three weeks.

3. Reporting and corrective action - Auditors will share the results of the audit with the provider and identify any corrective action that will be required to address noncompliance. If necessary, a case may be referred to the Division of Compliance Enforcement (DCE) for enforcement actions, which may include monetary penalties, sanctions, or termination of the provider’s contract.

4. Audit validation - A provider will submit Corrective Action Plans (CAPs) detailing how they will correct any noncompliance that was discovered during an audit. After CAPs have been completed, a validation audit will be conducted by CMS or by an independent auditor to determine whether the issues have been substantially corrected. This phase may last up to six months.

Contact Our Illinois CMS Audit Attorney

If you are facing an audit by CMS, you will want to make sure you provide all information requested and follow the correct steps during the audit process. The Law Offices of Joseph J. Bogdan, Inc. can provide you with legal representation during an audit, making sure your rights will be protected and helping you minimize enforcement actions and avoid the possibility of exclusion from Medicare/Medicaid. To schedule a free consultation and learn how we can help with your case, contact our Illinois Medicare/Medicaid audit lawyer by calling 630-310-1267.

Sources:

https://www.cms.gov/files/document/2021-program-audit-process-overview.pdf

https://changehealthcare.libsyn.com/medicare-advantage-making-sense-of-the-audit-universe