Medicare Blog

who audits medicare

by Clifton Wyman IV Published 2 years ago Updated 2 years ago

One of the primary tasks of the SMRCs is to conduct nationwide medical review as directed by CMS. SMRCs will evaluate medical records and related documents to determine whether Medicare claims were billed in compliance with coverage, coding, payment and billing guidelines.

Full Answer

What is the focus of a Medicare audit?

The focus of the reviews may include, but is not limited to, vulnerabilities identified by analysis of CMS data, the CERT program, professional organizations, and federal oversight agencies. Medicare contractors with the responsibility to audit are given the same guidelines regarding the type of review and reasons to deny.

How do Medicare contractors conduct Medicare audits?

Each type of contractor may use different methods to conduct audits, but they must all abide by overarching Medicare guidelines for medical review, denials, appeals, and payment recovery, as set forth by the Centers for Medicare and Medicaid Services (CMS).

Are You at risk of going through a Medicare audit?

If you treat Medicare patients, then you probably already know that there’s an ever-present threat of going through a grueling audit that could put you and your entire practice in trouble. In fact, this threat could be the riskiest part – other than having to continuously browse the Medicare guide – of treating Medicare patients.

How can I protect my practice from Medicare audits?

There are measures you can take to protect your practice. When it comes to avoiding audits, knowledge is power, so make it your mission to educate yourself and your staff on Medicare’s Local and National Coverage Policies.


What triggers a Medicare audit?

What Triggers a Medicare Audit? A key factor that often triggers an audit is claiming reimbursement for a higher than usual frequency of services over a period of time compared to other health professionals who provide similar services.

What does a Medicare auditor do?

As a Medicare auditor, you review health insurance information and documentation to ensure accuracy and locate errors or discrepancies. Your duties include reviewing billing and claims processes to ensure healthcare and medical service providers abide by Medicare regulations.

What are the two types of Medicare audits?

Types of Medicare AuditsRecovery Audit Contractor (RAC) Audits.The Certified Error Rate Testing (CERT) Audits.Probe Audits.Check the address on the letter and ensure that it is the address of your practice.Make contact with the auditors.Keep copies of all transmitted documents to the auditors.More items...

What happens if you fail a Medicare audit?

If you fail to comply with the request, you will not receive reimbursement for the submitted claims. Even if you comply but the documentation doesn't support what you billed for, you won't get reimbursement.

Are Medicare audits random?

For example, the Medicare program is required to make random audits of 10% of all Medicare providers on an ongoing basis. An audit or investigation can result from complaints by patients about the quality or appropriateness of the care they received, or how they were billed for their care.

How long does a Medicare audit take?

After the provider is “targeted” using data analytics, the MAC performs up to three rounds of "probe and Educate." Each round takes about 90 days—30 days for MAC to review the claims, a few days to schedule an educational call, 45 days for providers to show improvement—and is centered around a one-on-one educational ...

How far back can Medicare audits go?

Medicare RACs perform audit and recovery activities on a postpayment basis, and claims are reviewable up to three years from the date the claim was filed.

Who performs RAC audits?

There are currently three firms that administer RAC audits, according to CMS' website: Performant Recovery Inc., Cotiviti LLC and HMS Federal Solutions, and the company that comes calling depends on your agency's geographic region.

How far back can Medicare recoup payments?

(1) Medicare contractors can begin recoupment no earlier than 41 days from the date of the initial overpayment demand but shall cease recoupment of the overpayment in question, upon receipt of a timely and valid request for a redetermination of an overpayment.

What triggers RAC audit?

RAC audits are not one-time or intermittent reviews and can be triggered by anything from an innocent documentation error to outright fraud. They are part of a systematic and concurrent operating process that ensures compliance with Medicare's clinical payment criteria, documentation and billing requirements.

What are CMS audits?

These program audits measure a Sponsoring organization's compliance with the terms of its contract with CMS, in particular, the requirements associated with access to medical services, drugs, and other enrollee protections required by Medicare.

What is a RAC audit in Medicare?

What does a Recovery Audit Contractor (RAC) do? RAC's review claims on a post-payment basis. The RAC's detect and correct past improper payments so that CMS and Carriers, FIs, and MACs can implement actions that will prevent future improper payments.

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