Medicare Audit

Medicare Audit Background

The Centers for Medicare & Medicaid Services (CMS) has consistently increased efforts to identify and pursue overpaid claims from healthcare providers. CMS wants to ensure that healthcare providers are paid only for services that meet statutory and regulatory requirements; comply with provider contractual obligations and provider conditions for participation in the Medicare program; and meet CMS payment criteria or Medicare coverage criteria. With an arsenal of law enforcement and entities specifically hired to conduct medical records reviews and Medicare audits, healthcare providers who participate in the Medicare program are at risk for having to defend a Medicare audit and recoupment of previously paid claims.


The Medicare Audit Process

CMS contracts with entities to perform routine and ad hoc post payment audits. The audit starts with a CMS contractor’s request for medical records. Those records arethen reviewed and an audit report is generated which will reveal any non-compliance and whether action will be taken to take back the money that was paid to the provider.

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The Medicare Determination

A claim by claim determination involves a sequence of denials for the claims actually reviewed. For each claim that is denied, CMS will calculate the amount paid for those denied claims and make a demand for a return of those payments only. An extrapolation, on the other hand, involves a statistical calculation of a denial rate based on a sampling of the reviewed claims which is then applied to all of the claims that the provider submitted to CMS during a specific period of time. That denial rate is then applied to all reviewed and non-reviewed claims resulting in a much larger over payment demand. In either event, the calculated amount is considered an “overpayment” to the provider.


Provider Concerns

When CMS determines that an overpayment to the provider was made, CMS will notify the provider that the provider must return the payments. The provider has an opportunity to appeal the determination. Providers are encouraged to seek legal representation during the appeal process. In addition to a demand for repayment of previously paid claims, Medicare audits can result in the revocation of a provider’s
billing privileges with the Medicare program.


Medicare Audit Defense

The Martin Law Firm, P.C. routinely represents Physicians, Chiropractors, Physical Therapists, and other healthcare providers in the defense of the Medicare audit and overpayment determination. The defense includes assistance with all states of the appeal process. We use experts to prepare a substantive defense to the CMS audit determinations and we challenge the legal sufficiency of the audit.