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Seven Things To Know When You Receive A Notice Of Investigation From The Department Of Health

20 Helpful Tips to Prepare For a Medicare Audit & Site Visit From a Medicare Contractor

By George F. Indest III, J.D., M.P.A., LL.M., Board Certified by The Florida Bar in Health Law

When a healthcare provider receives notice of an audit or site visit from Medicare, the Medicare Administrative Carrier (MAC), or the Integrity Contractor, they must act quickly. These auditing organizations tend to move swiftly, with little warning and even less opportunity for preparation.  Below is a list of tips meant to help you to prepare for the on-site visit that will shortly follow.

Many items on this list may seem common sense to the reader;  however, they have presented  problems in many different audits in which I have participated.

If you would like to see a sample audit notification letter from CMS Zone 7, click here.

Tips to Follow Before and During the Audit Process and Site Visit.

1.     Double-check to make sure the address of the site visit is correct and all relevant information is included in the notice you receive.

2.    Call and make telephone contact with the auditors before-hand. Introduce yourself and ask for an explanation of the purpose of the audit. The auditor may not always give you this information. Also, provide any specific instructions on getting to your office, especially if security access is needed.

3.    Immediately call and advise your health care attorney and have him/her present at the audit and site visit.

4.    If the site visit is set for a branch office, make sure the appropriate administrative personnel and at least one of the treating providers who sees Medicare patients are in that office on the day of the site visit. Have them present to answer any questions that the auditors may have.

5.    Conduct a self-inspection of your office immediately; call for an emergency house-keeping visit to clean if necessary. Ensure that the office is presentable, that all areas are clean and organized, and that all necessary items are in place.

6.    Check all of your patient health records to ensure they are up to date, securely stored and compliant with HIPAA standards. Make sure no records or client information can be seen by any other patient or visitor to your office.

7.    Check to make sure all necessary licenses and certificates are up to date and that they are displayed clearly and prominently, especially your CLIA certificate (if you have one). Auditors always check and photograph all licenses and certificates hanging on the wall.

8.    If you have any medications or drugs of any kind in the office, especially crash cart medications, check to make sure they are not expired. Remove and replace any expired medications.

9.    Have a separate room set aside for the auditors with chairs and a flat surface (desk or table) for them to use as their meeting room, conference room, and interview room.

10.    Ask for valid photo identification and identifying information from each member of the audit team. Copy or record this information.

11.    Be aware that the auditors will scrutinize and ask about any policies and procedures for narcotics or pain medications.

12.    Select one primary employee as a contact person with the auditors (and your attorney).

13.    You will be asked if you prescribe any narcotics or pain medications for any MedicareMedicaid or Tricare patients. A “yes” answer is going to cause you future problems, but don’t lie.

14.    Keep a record of every document or paper you offer or provide to the auditors during the site visit. Do not allow auditors to leave with your originals or your only copy. Make copies or offer to send a copy later.

15.    If required records are in another location, don’t exhaust yourself trying to get them during the audit. Offer to obtain these and forward them the next day.

16.    Don’t guess at the answers to the questions asked by the auditors. If you don’t understand what is asked, request clarification. If you don’t know, say you don’t know. Offer to obtain and provide the information later.

17.    Anticipate being asked for your list or formulary of medications/drugs used in your treatment/care protocols.

18.    Refrain from suggesting any evidence of wrongdoing, and do not ask if what you are doing is right or wrong. Do not voluntarily suggest that you may be doing anything incorrectly.

19.    Ask questions to the auditors instead. Ask for their opinions on different matters. But don’t accept what an auditor says as being dispositive. Check later with your healthcare attorney.

20.    If additional time is needed to submit documents or information, request it by telephone and confirm it in writing. Maintain good copies and write down a list of any documents later sent to auditors.

Although this list does not cover every aspect of the audit process, it should provide you with a good starting point in preparing for any upcoming audit involving a site visit. For even more information, click here to read one of my prior blogs on this topic.

Don’t Wait Until It’s Too Late; Consult with a Health Law Attorney Experienced in Medicare and Medicaid Issues Now.

The attorneys of The Health Law Firm represent healthcare providers in Medicare audits and RAC audits throughout Florida and across the U.S. They also represent physicians, medical groups, nursing homes, home health agencies, pharmacieshospitals and other healthcare providers and institutions in Medicare and Medicaid investigations, audits, recovery actions and termination from the Medicare or Medicaid Program.

For more information please visit our website at www.TheHealthLawFirm.com or call (407) 331-6620 or toll-free (888) 331-6620.

About the Author: George F. Indest III, J.D., M.P.A., LL.M., is Board Certified by The Florida Bar in Health Law. He is the President and Managing Partner of The Health Law Firm, which has a national practice. Its main office is in the Orlando, Florida, area. www.TheHealthLawFirm.com The Health Law Firm, 1101 Douglas Avenue, Suite 1000, Altamonte Springs, FL 32714, Phone: (407) 331-6620 or Toll-Free: (888) 331-6620.

Current Open Positions with The Health Law Firm. The Health Law Firm always seeks qualified individuals interested in health law. Its main office is in the Orlando, Florida, area. If you are a current member of The Florida Bar or a qualified professional who is interested, please forward a cover letter and resume to: [email protected] or fax them to (407) 331-3030.

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