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of claim denials are overturned
improvement in net patient revenue
of claims are collected within 90 days or less
clean claims rate
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Medicare Audits and Appeals

We Help Protect Healthcare Providers During Medicare Audits and Assist with Medicare Appeals When Necessary

Medicare audits can present significant risks for participating providers. If not handled appropriately, these inquiries can lead to both unjustified recoupment requests and reimbursement denials for pending claims. They can also lead to prepayment review of future claims, which can delay payments by as much as six months. If auditors believe that they have uncovered evidence of intentional Medicare billing fraud, these audits can also lead to additional scrutiny and the potential for civil—or even criminal—federal enforcement action.

As a result, when faced with an impending Medicare audit, a proactive and strategic approach is critical. Medicare participants must ensure that they know how to correctly respond to auditors’ requests for records and access, and they must be prepared to identify and rectify flaws in the audit process. While this takes time and effort, it is extremely important, as unjustified negative findings can lead to all of the consequences mentioned above.

Former Healthcare Fraud Enforcement Agents Assisting with Medicare Audits and Appeals

We help healthcare providers and other Medicare participants effectively manage Medicare audits and appeals. As our Medicare compliance team includes a former Regional Inspector General and Assistant Special Agent-in-Charge with the U.S. Department of Health and Human Services Office of Inspector General (HHS OIG), we are intimately familiar with both the Medicare billing guidelines and the federal government’s efforts to uncover and prosecute Medicare fraud.

Fee-for-service auditors contracted by the Centers for Medicare and Medicaid Services (CMS) play a major role in this process, and they have substantial authority to act on CMS’s behalf. As a result, when dealing with these auditors, Medicare participants need to be very careful. Medicare participants need to take an informed approach to protecting themselves during the audit process, and they must focus on preserving adequate documentation of the audit in case they need to file an appeal.

What Healthcare Providers Need to Know About Medicare Audits

A Medicare audit is not simply a review of a healthcare provider’s or other Medicare participant’s billing records. Instead, it is an invasive process that has a singular purpose: to recover as much money for the government as possible.

This is because of how Medicare auditors are compensated. While the Medicare audit process is ostensibly intended to uncover both overpayments and underpayments, auditors receive performance bonuses for uncovering fraudulent payments. As a result, this is their sole focus, and they take an aggressive approach to accusing healthcare providers and other Medicare participants of fraud. When in doubt, they will err on the side of claiming an overpayment—and then it falls on the provider to overcome these allegations and prove that recoupment and other penalties are unwarranted.

While this is unfortunate, it is the reality of the modern-day Medicare audit process. Medicare audits are not neutral processes, and they are not events that Medicare participants can simply let run their course. Instead, providers and other participants must intervene in the audit process, and they must take as much control as possible to ensure that they do not face unnecessary and unwarranted consequences.

Put our highly experienced team on your side

Dr. Stephen Taylor

DOL Consultant

Roger Bach

Former Special Agent (OIG)

Chris Quick

Former Special Agent

Kevin Smith

Former Assistant Regional Inspector General

Michael Koslow

Former Supervisory Special Agent (DOD-OIG)

James Hunt

Former Special Agent-in-Charge (DEA)

How We Help with Medicare Audits

At Fortis, we provide several forms of assistance to healthcare providers and other businesses that are facing Medicare audits. Our consultants have a proven track record of helping clients minimize the consequences of having their billing records scrutinized by CMS’s fee-for-service audit contractors. We provide assistance with all types of Medicare audits, including:

  • Certified Error Rate Testing (CERT) audits
  • Medicare Administrative Contractor (MAC) audits
  • Recovery Audit Contractor (RAC) audits
  • Unified Program Integrity Contractor (UPIC) audits
  • Zone Program Integrity Contractor (ZPIC) audits

When faced with a Medicare audit, many people assume that the best approach is to be an open book. They assume that showing they have nothing to hide will help facilitate a swift and favorable resolution. However, this approach can be very risky. Auditors working for MACs, RACs, UPICs, and ZPICs routinely make mistakes, and they will often overreach in an effort to allege as much overpayment as possible. As a result, compliance alone is not a sufficient defense. Instead, audit targets must engage with auditors during the process and take a proactive approach to ensuring a just outcome.

To help our clients avoid unwarranted liability flowing from Medicare audits, we provide services including:

  • Audit Preparation – Our consultants will work with you to prepare for the impending audit, including outlining the audit process, identifying all relevant records, and providing instructions to your personnel.
  • Risk Assessment – We will conduct a pre-audit review to assess the risk presented by the audit, and then we will help you make informed decisions about how best to approach the audit based on this assessment.
  • Audit Intervention – Our consultants will make direct contact with the MAC, RAC, UPIC, or ZPIC conducting the audit and inform them that all communications will flow through our team. We will also oversee the entire audit process to ensure that the auditors comply with all pertinent rules and regulations.
  • Identifying Flaws – Flaws during the Medicare audit process are common; and, more often than not, these flaws lead to unjustified negative outcomes. By overseeing the auditors’ work, our team will be able to identify these flaws proactively and address them before they lead to final conclusions.
  • Final Resolution – We will continue to play an active role through the final resolution of the audit process. If necessary, we will work with the audit contractor to negotiate a resolution that avoids unnecessary consequences such as prepayment review or Medicare exclusion.

Due to the risks involved, when facing a Medicare audit, it is important to start getting ready as soon as possible. Our consultants are available to assist immediately; and, with our nationwide presence, we can arrange to have people on the ground on a moment’s notice when necessary.

How We Help with Medicare Appeals

Our Medicare compliance team also provides assistance with Medicare audit appeals. If you are facing recoupments, payment denials, prepayment review, exclusion, or other consequences following a Medicare audit, our team can assist with seeking mitigation or reversal of these penalties. Our consultants regularly serve as expert witnesses, working alongside our clients’ legal counsel at all stages of the Medicare appeals process. If you would like to know more about our services for Medicare appeals, we encourage you to get in touch.

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FAQs: Protecting Your Healthcare Practice or Business During (or After) a Medicare Audit

What Does it Mean If I Have Been Selected for a Medicare Audit?

Being selected for a Medicare audit doesn’t necessarily mean anything—positive or negative. Fee-for-service audit contractors working with CMS conduct audits as a matter of course, selecting targets at random or based on apparent anomalies in their billing data. But, while being selected for an audit doesn’t necessarily indicate that your practice or business is non-compliant, you will still need to take a proactive approach to handling the audit in order to avoid unnecessary consequences.

When Can a Medicare Auditor Deny Payment for Pending Claims?

Medicare auditors can deny payment for pending claims when pending claims appear to be incorrect or when necessary to recoup previous overpayments. The Medicare Program Integrity Manual states that a payment denial is appropriate if: (i) there is reliable information that an overpayment exists, but the amount of the overpayment is not yet determined; (ii) there is reliable information that payments to be made may not be correct; and, (iii) the provider fails to furnish records and other information necessary to determine the amounts due.

How Should I Handle a Medicare Audit (MAC, RAC, UPIC, or ZPIC)?

If you are facing a Medicare audit conducted by a MAC, RAC, UPIC, or ZPIC, you should start preparing immediately. You do not want to let the audit run its course unchecked. At Fortis, we help Medicare participants take control of the audit process and steer their audits toward favorable resolutions.

Do I Need to Engage a Consulting Firm for a Medicare Audit?

While engaging a consulting firm for a Medicare audit is not strictly necessary, it is strongly recommended. These audits can present significant risks, and avoiding unnecessary consequences can be difficult. An experienced team of consultants, like the team at Fortis, can help ensure that the process goes as smoothly as possible and reduce the likelihood of needing to file an appeal.

What Are the Grounds to File a Medicare Audit Appeal?

There are several grounds to file a Medicare audit appeal, including both substantive and procedural errors during the audit process. At Fortis, we have extensive experience examining Medicare audits, and we can assist with identifying—and proving—all viable grounds for challenging Medicare auditors’ overpayment determinations.

Contact the Medicare Compliance Team at Fortis

If you are facing a Medicare audit or need to know more about filing a Medicare audit appeal, we invite you to get in touch. To speak with a senior member of our Medicare compliance team in confidence, please call 866-808-4160 or request a complimentary consultation online today.