Miami Medicare Audit Defense for Healthcare Providers
A Medicare audit is not a paperwork exercise. Every chart you send, every cover letter and every phone call becomes part of the record the auditor uses to decide whether you were paid correctly, and whether the problem stops at the sample. If your practice or facility in Miami-Dade is facing a Medicare audit, you need Miami Medicare audit defense counsel involved before the first records leave your office.
The Health Law Offices of Anthony C. Vitale, now practicing as Vitale, Suarez & Associates, P.A., has defended healthcare providers in Medicare audits from its office in Miami Lakes since 1982.
Which Medicare Audit Are You Facing?
- UPIC audit. A Unified Program Integrity Contractor looks for potential fraud, waste and abuse. Its findings can lead to an overpayment, a payment suspension or a referral to law enforcement.
- RAC review. A Recovery Audit Contractor reviews paid claims after the fact and is paid a contingency fee on what it recovers.
- Targeted Probe and Educate (TPE). Your Medicare Administrative Contractor reviews a set of claims in up to three rounds, with education between rounds. Continued errors can lead to a referral, prepayment review or extrapolation.
- SMRC review. The Supplemental Medical Review Contractor reviews specific services at CMS's direction.
- CERT review. The Comprehensive Error Rate Testing program measures improper payments, and errors it finds can still become overpayments.
- Prepayment review. Claims are held and paid only after your records are reviewed.
Payment Suspension: When the Cash Stops
Under 42 C.F.R. § 405.371, Medicare can suspend payments when it has reliable information that an overpayment exists or a credible allegation of fraud. A suspension does not require a final finding, and it can last long enough to threaten payroll. The notice gives you the opportunity to submit a rebuttal statement under 42 C.F.R. § 405.374, on a short deadline. A rebuttal is not an appeal. It is your first chance to be heard, and it should be built on the records, not on frustration.
What a Defensible Audit Response Looks Like
- Read the request and calendar the deadline the day it arrives.
- Identify every record the request covers: notes, orders, signatures, attestations, logs and billing data.
- Check the records as they exist today. Never alter, complete or backdate an old entry. A properly dated addendum is a correction. An overwrite is a problem.
- Organize the production with an index and a cover letter that says only what the records support.
- Keep an exact copy of everything you send and proof of delivery.
- Prepare for extrapolation if the request is a sample of a larger group of claims.
If your policy says notes are signed the same day but your audit log shows signatures weeks later, the policy exists on paper only. The auditor will read the log.
Records, Metadata and the Firm's Forensic Team
Auditors increasingly look past the printed note to the EHR audit trail: who created the entry, when it was signed and whether it was changed. The firm’s in-house IT and forensic investigations team reviews audit logs and metadata before records are produced, with experience in systems such as eClinicalWorks, Avisena and Medios EHR. A clean note on paper can still look defective in metadata. It is better to know that before the auditor does.
Strategic Legal Solutions for Healthcare Providers
Serving Providers Throughout Miami-Dade
The firm’s office is in Miami Lakes, in Miami-Dade County, and it represents physicians, clinics, home health agencies, hospices, DME suppliers, laboratories and therapy providers across the county. The firm’s attorneys work with clients in English and Spanish.
Frequently Asked Questions
What happens if I miss a records request deadline?
The claims are usually denied for missing documentation. You may still be able to appeal, but the record starts against you, so ask for counsel before the deadline passes.
Can a TPE audit lead to extrapolation?
Yes. If errors continue after the TPE rounds, the contractor can refer the provider for further action, which can include prepayment review or an extrapolated overpayment.
Can my billing company handle the audit response?
It can help gather the records. Deciding what to produce, what to say and what the records may expose is a legal judgment.
Is a Medicare audit the same as a fraud investigation?
No, but one can become the other. An audit asks whether claims were paid correctly. A fraud investigation asks why they were not.
The owner of a Tampa, Florida-area medical marketing company was sentenced to 70 months in prison today for his role in a $2.2 million Medicare fraud scheme involving the payment of kickbacks and bribes to fraudulent medical clinics in Miami in exchange for the referral of Medicare beneficiaries for expensive genetic tests that were medically unnecessary, and for his role in the illegal structuring of cash withdrawal transactions.
Assistant Attorney General Brian A. Benczkowski of the Justice Department’s Criminal Division, U.S. Attorney Maria Chapa Lopez of the Middle District of Florida, Special Agent in Charge Michael McPherson of the FBI’s Tampa Field Office and Assistant Inspector General Omar Perez of the U.S. Department of Health and Human Services Office of the Inspector General’s (HHS-OIG) Miami Regional Office made the announcement.