Be Prepared for a CMS Audit

The Centers for Medicare & Medicaid Services (CMS) has spent more than $1 trillion on health care programs so far this year. That sets the record for money spent by a single federal agency in a single year. With so much at stake, it should come as no surprise that CMS is conducting audits in an attempt to reduce waste, fraud and abuse in health care spending. Here are some important facts to keep in mind.

First, any provider can be subject to an audit. Providers selected for an audit will be notified by letter and will be required to provide treatment records, facilitate interviews with personnel and provide auditors with access to the facilities. The provider will generally have at least 30 days to submit the requested paperwork.

Next, a Medical Integrity Contractor (MIC) will create a preliminary audit report. Both the state and the provider will have an opportunity to comment on the draft report’s findings. A final draft is later created, and the state is again allowed to comment. CMS then finalizes the report and sends it to the state. The state Medicaid Integrity Office is responsible for pursuing the collection of any overpayments.

To ensure the audit process goes smoothly for your practice, you should:

  1. Check your address on the audit notice to ensure the auditors are able to find your location. Confirm the time and date.
  2. Ask your attorney to be present during employee interviews.
  3. Keep legible copies of all documents you submit to the auditors.
  4. Expect to be asked for your drug list or formulary. Typically, auditors request a list of all medications prescribed, dispensed, used or billed.
  5. Don’t guess at the answers to any questions the auditors ask you. If you or your staff members don’t know the answer to a question, say so.
  6. If you need more time to comply, you can request it by telephone, but you should confirm the request in writing.

A CMS audit can be a stressful process. Consult knowledgeable health care attorneys if you have questions about what to expect during an audit.

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