Frequently Asked Questions
How do Medicare audits happen?
CMS and government audit contractors sometimes select providers or pharmacies for audits at random, but the far more common scenario is that a Medicare audit results from various "triggers" associated with billed claims. Data mining and analysis of "outlier" patterns often helps the government target who and what to audit.
Can a Medicare audit result in a federal investigation?
Yes, if there are significant claim discrepancies identified by a Medicare or Medicaid audit, the audit results may be referred for further investigation to CMS, OIG, FBI, or state Medicaid agencies, such as OMIG. Accordingly, it is important to consult a qualified Medicare audit attorney at an early stage, before options become more limited.
Does a Medicare audit have licensing consequences?
Yes, depending on the audit findings and extent of any discrepancies, state regulatory and licensing agencies may be notified. In particular, Medicaid is a joint federal-state program, and both the federal government and state Medicaid agencies have an interest in regulating providers who bill these programs.
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