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Receiving a healthcare audit letter from the federal government can be a confusing and intimidating experience. Before fearing what this could mean for your practice, thoroughly read the audit letter to get a clear picture of which entity is making a request.
Several different government agencies are tasked with uncovering health care fraud to prevent further incidents. Under the direction of the Centers for Medicare and Medicaid Services (CMS), some agencies simply want further documentation or information that supports a claim.
Types of Audit Letters
There are essentially four types of audit letter that you can receive from the government:
• Medicare Administration Audit – this is a request to conduct medical reviews for fee-for-service claims. If you receive this type of letter, additional documentation is needed to justify the purchase of medical equipment or medical services for the patient.
• Recovery Audit – this is an attempt to identify and correct any overpayments or underpayments.
• Zone Program Integrity Audit – suspected cases of fraud fall under this category where the auditor reviews medical records, conduct site visits and interviews. The focus is to determine if there is a pattern of improper billing.
• Comprehensive Error Rate Testing – this is a random selection and review of statistically identified rates of improper payments.
Your Next Steps after Receiving an Audit Letter
As a healthcare provider, you should prepare to answer the audit letter. Inform your staff about the possibility of auditors visiting the facility. Develop a plan for responding to the request in a timely manner.
There are times when the audit letter is set directly to an employee who is responsible for billing Medicare for the services you provide. Make sure your staff is aware that receiving an audit letter from the government is a possibility.
Responding to the audit letter is never an option. Based on which entity sends the audit letter determines the time period to deliver a mandatory response. Although a timely response is vital, you should never rush it.
Consider the reasons why the information is being requested. You also want to be aware of the risks to your practice if incorrect or damaging information is given to a government agency. Therefore, it is in your best interest to speak with a qualified healthcare audit lawyer.
Hire a Healthcare Audit Investigation Lawyer
Before deciding on how you and your staff should respond to the audit request, you should hire a lawyer. He or she will confirm what is being requested and what information you should submit. Generally, the time sensitive nature of these letters require establishing a relationship with a competent healthcare audit attorney before one is received.
In this manner, you and your legal counsel can prepare a thorough response the audit request. He or she knows the law and the repercussions of missing a deadline. Your attorney can also advise on what is appropriate to send. If the audit ends with a determination of fraud, you may have several options such as rebutting and requesting a redetermination.
Legal representation can help to keep your healthcare practice providing much-needed services to patients.