A healthcare audit reviews billing records, medical charts, and claims data to determine whether a provider was properly paid under Medicare, Medicaid, or another government healthcare program. A data anomaly, a patient complaint, a random selection, or a referral from another agency can trigger audits. They can result in demands for repayment in the hundreds of thousands or millions of dollars.
They could even lead to potential criminal charges against a provider if there is probable cause to believe fraud was committed. None of these outcomes are automatic, and the direction an audit takes often depends on how early and how strategically a provider responds. A healthcare audit defense attorney reviews the government’s findings, challenges flawed sampling and extrapolation methods, and represents providers through every stage of the appeals process.
Hilder & Associates, P.C. represents physicians, pharmacies, home health agencies, and other healthcare providers facing federal and Texas state audits. Contact our firm to schedule a free consultation, or call us today at [phonenumber].
Who Conducts Healthcare Audits
Several different contractors and agencies can initiate a healthcare audit, and each one operates under its own rules and priorities:
- Recovery audit contractors: Private companies paid a percentage of the improper payments they identify through post-payment reviews of Medicare claims.
- Unified Program Integrity Contractors: Government contractors that investigate potential fraud, waste, and abuse across both Medicare and Medicaid claims.
- Medicare administrative contractors: Regional contractors responsible for processing Medicare claims and conducting routine prepayment and post-payment reviews.
- Texas Health and Human Services Commission Office of Inspector General: The state agency responsible for auditing Texas Medicaid providers and referring suspected fraud for prosecution.
Our attorneys handle disputes involving each of these agencies, drawing on broader experience built through our Medicaid and Medicare fraud defense work and our healthcare fraud defense practice.
Common Triggers for a Healthcare Audit
Certain patterns tend to draw the attention of Medicare and Medicaid auditors more than others:
- Billing patterns that fall outside the normal range for a given specialty or geographic area
- A patient or former employee complaint alleging improper billing
- A referral from a private insurer or another government agency
- Claims data suggesting services were billed but not documented
- Prior corrective action plans or past audit findings tied to the same provider
In many cases, there need not even be a trigger, since government agencies can audit a provider at any time.
What Happens During a Healthcare Audit
Most audits begin with a records request, giving the provider a limited window to produce charts, billing codes, and supporting documentation for a sample of claims.
Auditors often extrapolate the error rate found in that sample across a much larger universe of claims, which can turn a handful of disputed charts into a repayment demand far greater than the sample itself would suggest.
A strong defense often begins with reviewing the sample size, the statistical method used, and whether the selected claims fairly represent the provider’s broader billing.
Extrapolation is one of the most consequential parts of this process, and also one of the most frequently challenged. A small, poorly constructed sample can produce an error rate that does not reflect a provider’s actual billing practices, yet that rate is then applied to every claim within the audit period. Challenging the statistical validity of an auditor’s sample, including how claims were selected and whether the sample size was large enough to support a reliable conclusion, can substantially reduce or eliminate an alleged overpayment before the case ever reaches a hearing.
Once the audit is complete, the provider typically receives a written determination outlining any alleged overpayment and the reasoning behind it. Providers who disagree with that determination do not have to accept it as final. Our attorneys regularly assist clients in defending against government audits and investigations, challenging flawed findings before repayment demands take effect.
Appealing an Audit Determination
Medicare providers generally have several levels of administrative appeal available once an audit determination is issued, starting with a redetermination request, which is a written request asking the reviewing contractor to reconsider its initial decision, and potentially continuing through a hearing before an administrative law judge.
The Office of Medicare Hearings and Appeals outlines these stages in detail, and deadlines at each one are strict. Missing a single deadline can result in forfeiting the right to challenge that portion of the audit altogether, regardless of how strong the underlying facts are.
Texas Medicaid providers face a separate, state-specific appeals process through HHSC’s Medical and Utilization Review (UR) Appeals unit, which follows its own timelines and procedural requirements that differ from the federal Medicare track. Which process applies and whether every deadline along the way has been met often determine how much of a disputed overpayment a provider ultimately has to repay. In many cases, an early, well-documented response at the redetermination stage resolves a dispute long before it would otherwise reach a formal hearing.
Why Providers Choose Hilder & Associates, P.C.
Philip H. Hilder founded our firm after building a background in federal prosecution, and that experience continues to influence how our attorneys approach government audits and investigations today. Rather than treating an audit as a routine paperwork exercise, our team examines each finding the way a prosecutor would, looking for the weaknesses in the government’s own methodology.
We represent clients across the country, and our attorneys are equally comfortable negotiating a resolution with an auditor or defending a provider through a full administrative hearing when negotiation does not resolve the dispute. Our practice also covers healthcare fraud and Medicare and Medicaid fraud matters more broadly, so our attorneys can quickly recognize when an audit finding signals a larger investigation forming behind the scenes, and can adjust strategy accordingly before that risk fully materializes.
FAQs
What Is the Difference Between a RAC Audit and a ZPIC or UPIC Audit?
The practical difference comes down to what’s at stake. A RAC audit is a billing review, and the worst outcome is typically a repayment demand. A ZPIC or UPIC audit starts from a fraud suspicion, which means the findings can lead to a referral to law enforcement or a payment suspension in addition to any repayment sought. Providers facing a ZPIC or UPIC inquiry should treat it differently from a routine billing audit from the outset.
How Long Do You Have to Respond to an Audit Request?
Response windows vary by audit type and contractor, but they are typically short, often measured in days rather than weeks, so providers should not wait to seek legal guidance once a records request arrives.
Can a Healthcare Audit Lead to Criminal Charges?
Yes, an audit that uncovers a pattern of intentional overbilling or fabricated documentation can be referred to law enforcement for criminal investigation, which is why early legal involvement matters even when a case initially appears to be a civil billing dispute.
What Happens If You Ignore an Audit Request?
Failing to respond can result in an automatic finding against the provider, suspension of Medicare or Medicaid payments, and a determination based solely on the auditor’s initial assumptions rather than the provider’s actual records.
Talk to Hilder & Associates, P.C. About Your Healthcare Audit
A healthcare audit rarely resolves on its own, and the earlier a provider responds with a clear strategy, the more options remain on the table. Whether the matter involves a federal Medicare audit or a Texas Medicaid audit, we tailor each defense to the agency involved. Hilder & Associates, P.C. has spent years representing providers through exactly these disputes, from the first records request through a full administrative appeal. Contact our firm to schedule a free consultation, or call us today at [phonenumber] to discuss the status of your audit.
