Preparing and Responding to an Initial Medicaid Audit Request

Friday, July 17, 2015
By Lance O. Leider, J.D.

Florida health care providers servicing Medicaid patients are at a higher risk for audits than anywhere else in the country.  The unfortunate truth is that Florida has become synonymous with health care fraud.  As a result, auditing and subsequent overpayment demands are very real possibilities.

Facts You Should Know About the Medicaid Audit Process.

Should you find yourself, your facility or your health practice the subject of a Medicaid audit by your state Medicaid agency or audit contractor, there are a few things you should know.

The most important thing is that just because you are being audited, it does not mean that you or your business have done anything wrong.  State and federal governments conduct audits for many different reasons.  Typical ones include: special audits of high-fraud geographic areas, auditing of particular billing codes, randomly selected provider auditing and complaints of possible fraud.

If You Are the Subject of an Audit.

An audit will usually begin with the provider receiving an initial audit request, usually by letter or fax.  This request will serve to notify the recipient that it is the subject of an audit.  The initial letter will not always identify the reason for the audit.  It will, however, contain a list of names and dates of service for which the auditors want to see copies of medical records and other documentation.

Once the records are compiled and sent to the auditor, the process shifts and you are now going to have to dispute the auditor's findings in order to avoid overpayment.

The biggest mistake that someone who is the subject of an audit can make is to hastily copy only a portion of the available records and send them off for review.  The temptation is to think that because the records make sense to you, they will make sense to the auditor.  Remember, the auditor has never worked in your office and has no idea how the records are compiled and organized.  This is why it is so important to compile a thorough set of records that are presented in a clearly labeled and organized fashion that provide justification for every service or item billed.

Compiling a Response to an Initial Audit Request.    

The following are steps that you should take in order to compile and provide a set of records that will best serve to help you avoid any liability at the conclusion of the audit process:

1.    Read the audit letter carefully and provide everything that it asks for.  It's always better to send too much documentation than too little.

2.    If at all possible, compile the records yourself.  If you can't do this, have a compliance officer, experienced consultant, or experienced health attorney compile the records and handle any follow-up requests.

3.    Pay attention to the deadlines.  If a deadline is approaching and the records are not going to be ready, contact the auditor and request an extension before it is due.  Do this by telephone and follow up with a letter (not an email).  Send the letter before the deadline.

4.    Send a cover letter with the requested documents and records explaining what is  included and how it is organized as well as who to contact if the auditors have any questions.

5.    Number every page of the records sent from the first page to the last page of documents.

6.    Make a copy of everything you send exactly as it is sent.  This way there are no valid questions later on as to whether a particular document was forwarded to the auditors.

7.    Send the response package using some form of package tracking or delivery confirmation to arrive before the deadline.

Compiling all of the necessary documentation in a useful manner can be an arduous task.  If you find that you cannot do it on your own, or that there are serious deficiencies in record keeping, it is recommended that you reach out to an attorney with experience in Medicaid auditing to assist you in the process. To read one of our past blogs on this topic, click here.

Contact Health Law Attorneys Experienced in Handling Medicaid and Medicare Audits.

The Health Law Firm's attorneys routinely represent physicians, medical groups, clinics, pharmacies, durable medical equipment (DME) suppliers, home health agencies, nursing homes and other healthcare providers in Medicaid and Medicare investigations, audits and recovery actions.

To contact The Health Law Firm please call (407) 331-6620 or (850) 439-1001 and visit our website at

About the Author: Lance O. Leider is an attorney with The Health Law Firm, which has a national practice. Its main office is in the Orlando, Florida area.  The Health Law Firm, 1101 Douglas Ave., Altamonte Springs, FL 32714, Phone:  (407) 331-6620.

KeyWords: Medicare fraud, medicare, false billing, overpayment, Recovery Audit Contractor, RAC, Medicare audit, Medicare investigation, health care fraud, Medicare fraud attorney, Centers for Medicare & Medicaid Services, CMS, overbilling, audit defense attorney, legal defense lawyer, ZPIC, ZPIC audit, compliance officer, compliance program, The Health Law Firm reviews

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