What should I do if I'm audited by Medicare?

While a Medicare audit should not be cause for panic, it should be taken as seriously as an IRS tax audit. Medicare can audit physicians in one of two ways. Physicians can be audited in “pre-payment audits” where Medicare workers randomly examine physician records that have not yet been submitted to Medicare or physicians can be audited in “post-payment audits” which is a review of claims that have already been submitted for Medicare reimbursement. The majority of Medicare audits are conducted by mail but sometimes a federal agent will come to your place of business in order to conduct the audit.

 It is very important that all of your patient charts and billing records are well organized and easy to review. If the Medicare carrier who is conducting the audit finds a discrepancy between what you have billed Medicare and the actual cost of the medical services provided then you typically have three options. You can pay the assessment requested by Medicare, you can waive your right to appeal and submit evidence that the carrier’s conclusions were incorrect or you can request that the carrier look at a larger sample of your charts and records and maintain your right of appeal. If a Medicare carrier finds one instance of a billing error then Medicare is likely to instruct you on the importance of proper billing and request a refund for overpayment on that case. However, if a Medicare carrier finds a trend of overpayments then you may be facing repayment of significant amounts of money as well as civil and criminal penalties. 

Since the potential penalties are so serious, it is important that you contact your attorney as soon as you receive notification that Medicare will be conducting an audit. Your attorney can help you and your staff adequately prepare for the audit.