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Definitive Guide to
Medicare Audit Defense

Facing a UPIC, TPE, CERT or other type of Medicare audit?

Get informed with this definitive guide to Medicare audits so that you can understand the process. Remember, audits can be costly and should only be handled by a knowledgeable healthcare compliance professional. Our healthcare compliance specialists have worked for the federal government, most major health insurance companies, and state medical boards. Contact the experts at SHG to help you through a Medicare audit, or to help answer your questions.

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Part 1: Medicare Audit Contractors

Who Audits the Medicare Program?

MACS, RACS, UPICS, SMRCs, CERT

Before diving into the Medicare audit process, it’s important to know the players involved. Medicare contracts with several different entities to audit and review claims submitted to the Medicare program. Each has their own unique role in auditing providers and different processes.

MACs are primarily responsible for processing Medicare claims. They act as the primary contact between the Medicare program and the providers. MACs play a significant role in identifying overpayments and underpayments, conducting medical reviews, managing appeals, and providing education to providers. There are multiple MAC jurisdictions across the United States, each serving a specific geographic region.

RACs are designed to detect and correct past improper payments. They review claims on a post-payment basis and help in identifying overpayments made to providers and underpayments made to beneficiaries. Currently, there are five RACs in the U.S., each serving a specific region.

UPICs consolidate the work of the Medicare and Medicaid program integrity contractors into a single entity responsible for auditing both Medicare and Medicaid claims. They perform similar tasks to ZPICs, but on a broader scale. They cover five regions across the United States.

The SMRC conducts nationwide medical reviews of Medicare Parts A and B, and Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) claims for compliance with coverage, coding, payment, and billing practices.

The CERT program measures improper payments in the Medicare fee-for-service (FFS) program. The CERT contractor reviews a sample of Medicare FFS claims to determine if they were paid properly under Medicare coverage, coding, and billing rules. There’s one national CERT contractor for the entire United States.

  • SMRC: Noridian Healthcare Solutions, LLC is the SMRC contractor for all 50 states
  • PPI Medic: Qlarant is the PPI MEDIC contractor for all 50 states
  • I-MEDIC: Qlarant is the I-MEDIC contractor for all 50 states

I-MEDIC audits are internal Medicare audits that look for fraud waste and abuse in the Medicare Program. Qlarant conducts statistical sampling to determine outliers. This is often done at the request of law enforcement to generate evidence for criminal and civil cases against providers.

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Part 2: Types of Medicare Audits

When we say “Medicare Audit” we could be talking about several different types of audits. Each has their own processes and potential outcomes and each needs to be handled differently to ensure success. The following are the different categories of Medicare Audits:

Types of Medicare Audits

  • Targeted Probe & Educate (TPE) Program Audits
  • Unified Program Integrity Contractor (UPIC) Audits
  • Supplemental Medical Review Contractor (SMRC) Audits
  • Comprehensive Error Rate Testing (CERT) Audits
  • CMS Program Integrity Audits

This guide will describe in detail each different type of audit below.

Part 3: Understanding Medicare TPE Audits

The Targeted Probe and Educate (TPE) program is a proactive auditing initiative designed to ensure that healthcare providers comply with the requirements of the Centers for Medicare & Medicaid Services (CMS). These audits are designed to detect common errors and inconsistencies in the billing processes and to educate providers about best practices for billing.

A TPE audit is conducted by Medicare Administrative Contractors (MACs). These are private healthcare insurers that have entered into contracts with the CMS to process Medicare Part A and Part B (Medical Insurance) claims, as well as durable medical equipment (DME) claims.

When a provider has been selected for a TPE audit, the MAC will send them a notification letter. The selection can be based on various factors, such as the provider’s billing pattern compared to their peers, or due to the provider having a high denial rate. The notification letter will detail the reasons for the selection, what the audit will entail, and the date by which the requested documents should be submitted.

In the TPE audit, the MAC will request specific items that pertain to the claims that are being audited. These items may include medical records, documentation supporting the medical necessity of services billed, and any other information required to verify that the services were correctly billed. The documentation should also clearly show that the services were provided in accordance with all applicable Medicare rules and regulations.

The requested information should be provided by the due date stated in the notification letter. The method of submission will depend on the MAC’s preference; some may prefer mail, fax, or a secure electronic method. The provider should keep a copy of the submitted documentation and the proof of mailing or delivery.

After reviewing the submitted documentation, the MAC will send a letter to the provider detailing the findings of the audit. If any errors were found, the letter will describe them and explain why the billed services did not comply with Medicare’s rules. If the provider was compliant, they will also receive notification, indicating the audit is complete with positive results.

The outcomes of a TPE audit can vary depending on the findings:

  • No Errors Found: If the audit finds no errors, the MAC will send a letter indicating the audit is complete and no further action is required.
  • Errors Found: If errors are found, the provider will receive an offer for one-on-one education to help understand the issues identified. After this educational phase, the MAC may conduct another audit to verify that the provider has corrected the errors.
  • Continued Non-compliance: If the provider continues to be non-compliant after three rounds of TPE, the MAC may refer them to the CMS for possible further action. This can include 100% prepayment review, extrapolation, referral to a Recovery Audit Contractor (RAC), or other actions as stipulated by CMS regulations.

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Part 4: UPIC Audits

Unified Program Integrity Contractors (UPICs) are integral elements of the oversight mechanisms of the Medicare and Medicaid programs, created with the intention of detecting, preventing, and deterring fraud, waste, and abuse within these systems. This article aims to demystify UPIC audits, explaining how they are conducted, what they entail, and their potential outcomes.

UPIC audits are conducted by contractors hired by the Centers for Medicare & Medicaid Services (CMS). These contractors consolidate the work previously conducted by Medicare and Medicaid program integrity contractors, hence the term “Unified.” These auditors carry out their responsibilities across five different regions in the United States, each of which is covered by a specific UPIC.

When a provider is selected for a UPIC audit, they receive an initial request letter from the UPIC. This letter contains important details such as the purpose of the audit, the time period under review, and the specific patient records requested for the audit. The selection of providers for an audit is typically based on data analysis that identifies billing anomalies or patterns that suggest potential fraud, waste, or abuse.

The information requested during a UPIC audit typically includes medical records and other supporting documents that substantiate the claims made by the provider. This may cover various items such as clinical notes, lab results, hospital records, billing records, and any other relevant information that confirms that the services were medically necessary, were actually provided, and were billed correctly in accordance with Medicare or Medicaid rules.

The requested information should be submitted by the provider by the deadline specified in the UPIC’s request letter. The exact method for submitting the requested documentation may vary based on the UPIC’s requirements, but it often includes options such as mail, fax, or secure electronic submission. Providers are advised to retain a copy of all submitted information, as well as proof of the submission, for their records.

Following the review of the submitted documentation, the UPIC will compile its findings and send the provider a detailed review results letter. This letter will explain whether overpayments, underpayments, or other discrepancies were found during the audit. If errors were found, the letter will explain them in detail and provide the reasons why the claims did not comply with Medicare or Medicaid rules.

The outcomes of a UPIC audit can vary depending on the findings:

  • No Errors Found: If the UPIC audit finds no issues with the provider’s claims, the audit concludes, and no further action is required.
  • Errors Found: If errors are identified, the provider may be required to return overpayments, potentially face a fine, or receive education and guidance on how to avoid such errors in the future. The provider will also have the right to appeal the findings.
  • Potential Fraud Identified: In cases where the audit uncovers potential fraudulent activity, the UPIC may refer the provider to law enforcement for further investigation, which could result in criminal charges, civil fines, or exclusion from federal healthcare programs.

UPIC audits, though rigorous, play a critical role in safeguarding the integrity of the Medicare and Medicaid programs. Providers who maintain robust compliance programs and thorough documentation are well-equipped to navigate these audits successfully.

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Part 5: SMRC Audits

The Supplemental Medical Review Contractor (SMRC) is a key component of the Medicare program’s ongoing effort to ensure accurate and compliant claims submissions. Their work involves conducting nationwide audits to identify and address improper payments and provide valuable feedback to the Centers for Medicare & Medicaid Services (CMS) about overarching issues within the system. This article will unpack the details of SMRC audits, including the audit process and potential outcomes.

SMRC audits are conducted by contractors hired by CMS. The SMRC is responsible for nationwide medical review of Medicare Parts A and B and Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) claims. They conduct both complex and non-complex medical reviews based on various data analysis, Comprehensive Error Rate Testing (CERT) results, professional judgement, and input from the Department of Health and Human Services and CMS.

Providers are notified of an SMRC audit through an initial request letter sent by the SMRC. This notification outlines the purpose of the audit, the claims or time period being reviewed, and the specific documentation required for the audit. The selection of providers for these audits is usually based on areas identified as high risk for improper payments.

The SMRC will request documentation to support the claims under review. Depending on the focus of the audit, this might include medical records, clinical notes, lab results, billing records, proof of delivery for DMEPOS, and any other documents that substantiate the medical necessity, provision, and billing of the services or items in question.

The provider must submit the requested documentation by the deadline stated in the initial request letter. Methods of submission can vary, but they usually include mailing, faxing, or a secure electronic submission method. Providers are strongly encouraged to retain copies of all submitted documents and proof of their submission.

Upon reviewing the documentation, the SMRC will compile its findings and issue a detailed review results letter to the provider. If errors were detected, the letter will explain them and provide the reasons why the services did not comply with Medicare rules and regulations.

The outcomes of an SMRC audit depend on the findings of the audit:
No Errors Found: If no errors are detected, the SMRC will indicate that the audit is complete and no further action is needed.
Errors Found: If errors are found, the provider may have to repay overpayments, and they may also be offered education to help avoid these errors in the future. Additionally, the provider has the right to appeal the findings.
Significant Issues Identified: If the audit identifies significant issues, the SMRC may refer the case to CMS for possible further action. This could include a referral to a Recovery Audit Contractor, law enforcement, or other appropriate parties.
SMRC audits are an important part of ensuring compliance within the Medicare program. Providers can best prepare for these audits by maintaining accurate, thorough, and timely documentation, and by staying up-to-date on Medicare’s billing rules and regulations.

Part 6: CMS Audits

The Centers for Medicare & Medicaid Services (CMS) is a federal agency within the United States Department of Health and Human Services (HHS) responsible for overseeing and administering the nation’s major healthcare programs, including Medicare, Medicaid, and the Children’s Health Insurance Program (CHIP). One of the agency’s most critical functions involves conducting audits to ensure program integrity, detect and prevent fraud, waste, and abuse.

CMS audits are carried out by various contractors hired by CMS. The type of audit and the contractor conducting it depends on the specific focus of the review. These contractors can include Medicare Administrative Contractors (MACs), Recovery Audit Contractors (RACs), Unified Program Integrity Contractors (UPICs), Supplemental Medical Review Contractors (SMRCs), and others. Each of these contractors focuses on different areas of oversight and serves different regions of the country.

When a provider is selected for a CMS audit, they receive a notification letter from the respective contractor conducting the audit. This letter contains details such as the purpose of the audit, the time period and claims under review, and the specific documentation required. Providers are selected for audits based on various criteria, such as billing patterns, high denial rates, or identified areas of risk for fraud, waste, and abuse.

A CMS audit typically involves a request for medical records and other supporting documentation that validate the claims made by the provider. The specific documents requested depend on the type of audit being conducted but generally include evidence supporting the medical necessity, provision, and correct billing of the services or items in question.

Providers are required to submit the requested documentation by the deadline specified in the request letter. The mode of submission often includes mailing, faxing, or secure electronic submission. Providers should keep copies of all submitted information, as well as any proof of submission.

After reviewing the documentation, the contractor will compile its findings and send a detailed review results letter to the provider. This letter outlines whether the review found overpayments, underpayments, or other discrepancies. If errors are identified, the letter will explain them in detail and provide the reasons why the claims did not comply with CMS rules and regulations.

The outcomes of a CMS audit vary based on the findings:

  •  No Errors Found: If no errors are detected, the audit concludes with no further action required from the provider.
  •  Errors Found: If errors are found, the provider may need to return overpayments or could face penalties. Additionally, providers may receive education on the correct billing practices to prevent future errors.

 Fraud, Waste, or Abuse Detected: In cases where potentially fraudulent activity or significant waste or abuse is detected, the case can be referred to law enforcement for further investigation, which can result in civil penalties, criminal charges, or exclusion from federal healthcare programs.

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Part 7: The Medicare Appeals Process

The Medicare Appeals Process: An In-depth Guide

The Medicare appeals process is an essential part of the Medicare system, allowing beneficiaries and providers to dispute decisions made by Medicare about coverage or payment. Understanding the Medicare appeals process, including the steps involved, the required timelines for filing an appeal, and strategies on how to win a Medicare appeal, can be vital for a successful outcome.

Redetermination, the first step in the Medicare appeals process, involves requesting a review of the initial claim decision. This review is typically conducted by the same Medicare Administrative Contractor (MAC) that made the initial decision. The party appealing the decision—either the beneficiary or the provider—must submit their request for redetermination within 120 days of receiving the Medicare Summary Notice (MSN) or Remittance Advice (RA) detailing the claim decision.
To file a Medicare appeal at this stage, the appellant should provide pertinent information such as their name, Medicare number, specific services or items being appealed, and any supporting documents that argue why the payment decision should be reversed.

If the redetermination does not yield a favorable outcome, the next step in the Medicare appeal process is to request a reconsideration. This second level of appeal is performed by a Qualified Independent Contractor (QIC) and must be filed within 180 days of receiving the redetermination decision.
In the reconsideration request, include the same information required for redetermination, plus any additional supporting documentation. This is an essential step in learning how to win a Medicare appeal, as the more evidence supporting the need for the disputed service or item, the higher the chances of a successful appeal.

Should the reconsideration still not yield a favorable result, appellants can escalate their Medicare appeal to the level of an Administrative Law Judge (ALJ) hearing. This is a more formal process and usually involves a hearing with the appellant, the ALJ, and possibly other parties involved in the claim.
To request an ALJ hearing, the amount remaining in controversy must meet a minimum threshold, updated annually. Requests for an ALJ hearing must be filed within 60 days of receiving the reconsideration decision.
To prepare for the ALJ hearing and increase the chances of winning the Medicare appeal, appellants should review their case thoroughly, ensure all supporting documentation is in order, and be prepared to present their argument clearly and convincingly.

If the ALJ hearing decision is unfavorable, appellants can request a review by the Appeals Council. There is no minimum amount in controversy required for this level, but the request must be filed within 60 days of receiving the ALJ’s decision. The Appeals Council can either decide the case themselves or send it back to an ALJ for another hearing.

The final step in the Medicare appeals process is a judicial review in federal court. This step is only available if the amount remaining in controversy meets a higher minimum threshold, updated annually. The request for judicial review must be filed within 60 days of receiving the Appeals Council’s decision.
Understanding the Medicare appeal timeframe for each stage is crucial in ensuring the timely filing of a Medicare appeal. The process may seem complex, but knowing how to file a Medicare appeal and how to appeal a Medicare denial effectively can lead to a successful outcome.
The key to winning a Medicare appeal is a solid understanding of the Medicare appeal process, timely submission of all requests, and providing comprehensive and convincing supporting documentation that substantiates the need for the disputed service or item. It may also be beneficial to engage legal counsel or a healthcare advocate experienced in Medicare appeals for assistance throughout the process.

Part 8: Medicare Audit Defense

In the world of healthcare, Medicare audits are an inevitable part of doing business. These audits can feel like a daunting prospect, but with a clear understanding of the process and the right team supporting you, they don’t have to be overwhelming. In this section, we’ll discuss how to effectively respond to a Medicare audit and the importance of partnering with CCG Healthcare to ensure a successful outcome.

Medicare Audit Checklist

When you’ve received a notification of a Medicare audit, following this checklist can streamline the response process:

Carefully review the audit notice to understand what type of audit it is, what information is requested, and the deadline for responding.

Assign a dedicated team or individual to coordinate the audit response. This person should be knowledgeable about your organization’s policies, procedures, and documentation practices.

Collect all records and documents specified in the audit request. These might include patient records, billing information, and any other pertinent documentation.

Arrange your documentation in an organized, easy-to-review format that aligns with the audit request.

Before submitting your response, double-check all the documents to ensure nothing is missing and that they support the services billed.

It’s crucial to respond within the timeframe provided in the audit letter to avoid potential penalties. If more time is needed, you may request an extension, but it’s not guaranteed to be granted.

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Part 9: Medicare Audit Defense Checklist

Here’s Some Insight into How We Defend an Audit

Pre-Audit Preparation

  1. Understand Medicare regulations and guidelines: Regularly review and understand the latest Medicare regulations, guidelines, and billing codes related to your services. Our compliance officers can provide you our decades of knowledge and experience in this area and train your staff.
  2. Establish a compliance program: We next implement a compliance program that includes regular internal audits and staff training on accurate documentation and billing practices.
  3. Documentation: We help you ensure all patient files are complete, up-to-date, and easily accessible. Documentation should clearly demonstrate medical necessity and align with billed services.

Once the Audit Notification is Received

  1. Audit Notification: We then review the audit notice for type of audit, scope, timeframe, and what information is being requested.
  2. Response Team: We work with you to assign a response team or individual responsible for gathering information, communicating with auditors, and coordinating the audit response.

Documentation Collection

  1. Collect Requested Documents: We help you gather all documents specifically requested in the audit notice. This might include patient records, clinical notes, lab results, billing records, and more.
  2. Organize Documents: We ensure you have arranged documents in a logical, organized manner that aligns with the audit request, making it easier for auditors to review.
  3. Duplicate Documents: We make and preserve copies of all documents being sent to the auditors for your own records.

Response Preparation

  1. Write a Response Letter: This is where our work really gives you an edge. We draft an introductory letter in your response that outlines what documents are included and addresses the issues raised in the audit notice.
  2. Double-check Documents: We then review all documents one last time to ensure nothing is missing and that all information supports your case.

Audit Response Submission

  1. Submit Response: We send your response by the deadline stated in the audit notice. Use certified mail or another method that provides proof of submission.
  2. Confirm Receipt: We will follow up with the audit contractor to confirm they received your response.

Post-Submission

  1. Monitor Communication: Watch for any communication from the auditor and respond promptly to any further requests for information.
  2. Audit Results: Once you receive the audit results, we review them carefully. If there are unfavorable findings, we consider whether to appeal and update our compliance plan.
  3. Appeal Process: If appealing, we understand the different levels of the Medicare appeals process and the timeline for each and can work with legal counsel to get the appeal filed.
  4. Implement Changes: If the audit identified issues, we implement any necessary changes to your practice to correct these problems and prevent them from occurring in the future.

This checklist is a general guide to responding to a Medicare audit. The specifics of your response may vary depending on the type of audit and the unique circumstances of your practice. Having an experienced Medicare audit defense team can be highly beneficial in navigating this process.

Part 10: Medicare Audit Timelines

Below are the general timelines to respond to various Medicare audits. Please note that these timelines may vary, and you should always refer to your specific audit notification for the exact timeframe provided.

Medicare Administrative Contractors (MACs) generally request that providers respond to post-payment audits within 45 calendar days of the date of the request.

For ZPIC audits, the initial response time is usually 30 calendar days from the date of the audit letter.

Similar to ZPIC audits, UPICs generally request providers to respond within 30 calendar days of the date of the audit letter.

For CERT audits, providers usually have 75 calendar days from the date of the documentation request letter to respond.

For the TPE program, providers are typically required to respond within 45 calendar days from the date of the request.

Please remember, it’s crucial that you respond within the timeframe provided in the audit letter to avoid negative repercussions, such as claim denials or payment recoupments. If more time is needed, it may be possible to request an extension, but the granting of extensions is at the discretion of the auditing contractor. Also, the above timelines refer to the time to respond with documentation. The actual audit process, including review and final determination, may take much longer. Always consult with a compliance expert to ensure you’re responding correctly and within the appropriate timeframe.

How SHG Healthcare Can Help

We’ve worked for the federal and state governments as well as most large insurance companies – we know how this process works and how to set you up for success. When it comes to responding to a Medicare audit, the stakes are high. Audits can lead to costly recoupments and even place providers on pre-payment review, significantly impacting cash flow. Partnering with SHG for your audit response and compliance planning can prove invaluable in such circumstances.

SHG’s team of experts brings years of experience in dealing with Medicare audits. Our team understands the intricacies of the audit process and can assist you in crafting a thorough, compelling response

SHG can help you develop a robust compliance program tailored to your organization’s specific needs. Our team will guide you through implementing practices that align with Medicare’s standards, reducing your risk of triggering future audits.

SHG takes a proactive approach to Medicare audit defense, ensuring your practice is prepared well before an audit notice lands in your mailbox. We provide regular staff training and conduct internal audits to ensure you’re always in compliance.

The financial implications of a poorly managed Medicare audit can be severe. SHG’s expert guidance can help you avoid costly recoupments or being placed on pre-payment review.

In conclusion, while Medicare audits may seem daunting, you don’t have to navigate them alone. With the right preparation and the expert team at SHG by your side, you can face any Medicare audit with confidence and peace of mind. Reach out to SHG today and let us guide you through your Medicare audit response process

How We Approach Medicare Audit Defense

Navigating the often-complex terrain of Medicare audits can be an overwhelming task for healthcare providers. With stringent rules, evolving compliance requirements, and the severe consequences of non-compliance, a Medicare audit can seem like an insurmountable challenge. Whether you’re facing a UPIC audit, TPE audit, or another type of Medicare review, having a seasoned Medicare audit defense team by your side is a strategic necessity. That’s where our expertise comes into play.

Our organization brings a robust blend of experience, insider knowledge, and dedication to your Medicare audit defense. Boasting a team of former insurance Special Investigation Unit investigators and Medicare Fraud investigators, we offer a unique perspective, valuable insight, and unmatched expertise in addressing audit defense.
Drawing from our deep understanding of the Medicare system’s inner workings, we are proficient in successfully defending against various audits, including UPIC audit defense, and TPE audit defense. We’re here to serve as your dedicated and reliable partners, helping you navigate the Medicare audit process with confidence and integrity.

We believe that the best defense is a proactive offense. Our team works diligently to ensure that your practice is equipped with robust compliance programs that align with Medicare’s standards. We provide thorough education to your staff about best practices, accurate documentation, and the nuances of various billing codes, laying a solid foundation that significantly reduces the likelihood of triggering an audit.

When faced with an audit, we employ a meticulously crafted defense strategy tailored to your unique situation. Our team will closely review the audit’s focus, methodically examine your claims, scrutinize the supporting documentation, and carefully assess any potential areas of concern. We aim to uncover every crucial detail, leaving no stone unturned in your defense.

We not only prepare a robust response to the audit findings but also represent you throughout the process. Our defense specialists will communicate with the auditors on your behalf, ensuring your rights are protected, and your case is presented effectively and persuasively.

Our proven track record in Medicare audit defense stems from our profound understanding of Medicare’s auditing process, regulatory requirements, and potential pitfalls. Our team’s unique blend of experiences – from investigating potential fraudulent activities to handling intricate audits – places us in an advantageous position to help our clients achieve successful outcomes.

At the heart of our work is a steadfast commitment to our clients. We understand the pressures and stakes involved in a Medicare audit. That’s why we pour our energy, experience, and expertise into crafting an unassailable defense strategy for you. When it comes to Medicare audit defense, don’t face the challenge alone. With our dedicated team of seasoned professionals by your side, you can confront any audit with confidence, knowing that you have industry-leading expertise supporting you every step of the way. Reach out to us today and let’s start building your defense.

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Safe Harbor Group: A Nationally Trusted Healthcare Compliance Partner

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