You Received an Audit Letter, Now What?

It’s not unusual for our office to receive a phone call from a healthcare provider stating that they received an audit request. Some call us after they have already responded and now have additional concerns. Others call us before they have taken any action. As the government continues to find value in recovering overpayments, we anticipate we will see an increase in the number of audits by Medicare, Medicaid and TRICARE, as well as private insurers.

There are two types of audits, a prepayment review and an analysis after claims have been paid. Prepayment reviews may result in a payment denial and request for additional information. Post-payment reviews likely will result in a notice requesting additional charts/records. If it is determined an overpayment is made, a reimbursement request likely will be made.

Audit requests can come from a variety of places. They can come directly from Medicare Administrative Contractors (MACs), Recovery Auditor Contractors (RACs) and Unified Program Integrity Contractors (UPIC).

Of course it’s always a good idea to have a compliance program in place to prevent, or at least reduce the risk of an audit. However, if your practice does become the target of an audit, there are some steps you can take to reduce your liability.

While you should never ignore an audit request, you also should not just send in records.

It’s best to contact a qualified healthcare attorney who is knowledgeable and experienced. He or she likely will recommend a review of your records to ensure that any deficiencies have been fixed. However, do not make any corrections in the record. All changes should be made as amendments and must be noted with the date and time. You do not want an auditor to think you are attempting to hide anything.

Do not turn this critical task over to just anyone in your office. Make sure you have a qualified individual going over these medical records. He or she will know what to look for and to make sure proper steps are taken to correct any problems. You never know who in your office may be on the receiving end of that letter. That is why it is important to train your entire office staff ahead of time to immediately notify you if an audit request is received.

Conducting in-house audits also may help you to detect other problems before they come to the attention of an auditor and to make sure that things are handled properly in the future.

Audit requests are time sensitive, do not delay taking action. The Health Law Offices of Anthony C. Vitale has extensive experience representing clients in audits and overpayments and we can represent your interests through all of the stages of the overpayment appeals process. In addition, if you find yourself the target of a fraud investigation, our team can assist you every step of the way.

Contact us for additional information at 305-358-4500 or send us an email to and let’s discuss how we might be able to assist you.

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The Health Law Offices of Anthony C. Vitale