If you are a healthcare provider facing a Medicare audit, you need to take it seriously from the moment you receive notice. Our Medicare audit defense lawyer protects your practice, your revenue, and your ability to continue participating in federal healthcare programs. Medicare audits can result in massive overpayment demands, exclusion from the program, and referrals for prosecution for healthcare fraud.
Call Hilder & Associates, P.C. at (713) 234-1416 or contact us online to schedule a free consultation with our Medicare audit defense lawyer who will review your case, explain your options, and help you build a strong defense strategy.
What Is the Purpose of Medicare Audits?
Medicare audits verify that providers are billing correctly and that the services they submit for reimbursement are medically necessary, properly documented, and coded accurately. The Centers for Medicare and Medicaid Services (CMS) uses multiple types of audits to identify billing errors, overpayments, and potential fraud across the healthcare system.
Some audits are routine and selected through random sampling, while others focus on providers whose billing patterns appear outside normal ranges. Whether chosen randomly or identified through data analysis, the process requires a prompt and thorough response. An inadequate or delayed reply can turn a routine review into a more serious investigation.
Types of Medicare Audits
Recovery Audit Contractors (RAC) Audits
Recovery Audit Contractors (RACs) are private companies hired by CMS to identify and recover improper Medicare payments. RACs review claims post-payment and look for overpayments and underpayments. If a RAC determines that you were overpaid, it will issue a demand letter requiring repayment.
Providers investigated by the U.S. Department of Health and Human Services Office of Inspector General (HHS-OIG) in connection with RAC findings may face additional scrutiny beyond simple repayment.
Medicare Administrative Contractors (MACs)
Medicare Administrative Contractors (MACs) are responsible for processing Medicare claims and conducting both prepayment audits and retrospective audits within their assigned jurisdictions. MACs may flag claims before or after payment based on several factors, including the following:
- Unusual billing volume compared to peers
- Repeated use of specific billing codes
- Claims that exceed expected cost thresholds
- Documentation that does not support the level of service billed
- Patterns that suggest upcoding or unbundling
Targeted Probe and Educate (TPE) Audits
Targeted Probe and Educate (TPE) audits focus on providers and suppliers who have high claim error rates or unusual billing patterns. Under a TPE review, a MAC selects a small sample of claims and reviews them for compliance.
If errors are found, the provider receives education on proper billing practices and is audited again. Providers who fail three rounds of TPE review may be referred for additional action, including referral to CMS or the HHS-OIG.
Unified Program Integrity Contractor (UPIC) Audits
Unified Program Integrity Contractor (UPIC) Audits are among the most serious Medicare reviews a provider can face. UPICs have broad authority to investigate suspected Medicare and Medicaid fraud, and their findings can lead to serious consequences, including the following:
- Immediate suspension of Medicare payments
- Revocation of billing privileges
- Referral to the HHS-OIG or the U.S. Department of Justice
- Imposition of civil monetary penalties under 42 U.S.C. § 1320a-7a
- Exclusion from all federal healthcare programs
Zone Program Integrity Contractors (ZPICs)
ZPICs were the predecessors to UPICs and performed many of the same functions, including investigating suspected fraud, waste, and abuse in Medicare billing. Although CMS has largely transitioned to the UPIC model, some references to ZPIC investigations still appear in active cases. Providers who were previously under ZPIC review may now find their cases handled by a UPIC, and the investigative scope can expand during the transition.
Comprehensive Error Rate Testing (CERT) Program Audits
The CERT program measures the national Medicare improper payment rate by reviewing a random sample of claims. If your claims are selected for a CERT review, you will need to submit supporting documentation promptly:
- Medical records for the dates of service under review
- Physician orders and referral documentation
- Certificates of medical necessity
- Itemized billing statements
- Any prior authorization records
Why Partner With Hilder & Associates, P.C.?
Our attorneys at Hilder & Associates, P.C. represent healthcare providers nationwide in Medicare audit defense matters, from initial document requests through administrative appeals and federal court proceedings. When you partner with us, we build a defense strategy designed to resolve the audit efficiently and protect your practice from further legal complications:
- Audit response preparation: We review every claim under audit, identify documentation gaps, and prepare a comprehensive response that addresses each issue raised by the auditor.
- Statistical sampling challenges: When auditors extrapolate overpayment demands from a small sample of claims, our Medicare audit defense lawyers challenge the methodology, sample selection, and statistical validity of their calculations.
- Administrative appeals: Medicare provides a five-level appeals process under 42 U.S.C. § 1395ff, and we guide providers through each stage, from redetermination through federal court review.
- Fraud referral defense: If your audit has been escalated to a fraud investigation, we defend against allegations of healthcare fraud, False Claims Act liability, and program exclusion.
- Payment suspension appeals: We act quickly to challenge improper payment suspensions and work to restore your cash flow while the audit or investigation is pending.
- Compliance program development: After the audit is resolved, we help you implement internal compliance protocols to reduce the risk of future audits and enforcement actions.
FAQ: Common Questions About Medicare Audits
What Triggers an Audit?
Audits can be triggered by statistical outliers in billing data, patient or whistleblower complaints, referrals from other government agencies, or random sampling programs. Providers who bill significantly above the national average for certain codes are more likely to be selected.
How Long Do I Have to Respond?
Response deadlines vary by audit type but are typically between 30 and 45 days from the date of the request. Missing a deadline can result in an automatic adverse determination, so our attorneys prioritize meeting every deadline the moment a case begins.
What Documents Are Required?
The specific records requested will depend on the audit type and the claims under review. In most cases, auditors will ask for the following:
- Complete medical records for each claim
- Physician orders and signed plans of care
- Billing and coding documentation
- Prior authorization approvals
- Certificates of medical necessity
- Operative reports or procedure notes
What Happens if a Mistake Is Found?
If the auditor identifies an error, the outcome depends on whether the mistake appears isolated or part of a pattern. A single coding error may result in a simple repayment request, while a pattern of errors can lead to extrapolated overpayment demands, referral for fraud investigation, or exclusion proceedings.
Speak with Our Federal Medicare Audit Defense Lawyer Today
Have you received an audit notice, a demand for repayment, or a payment suspension from CMS or one of its contractors? The deadlines in Medicare audits are strict, and every response you submit becomes part of the record that could follow your practice through years of appeals or enforcement proceedings.
Our Medicare audit defense firm will review audit findings, build a targeted defense, and fight to protect your practice and your livelihood. Speak with our team at Hilder & Associates, P.C. now to discuss your case. Call (713) 234-1416 or contact us online to schedule your free consultation.
