As federal and commercial payors continue to scrutinize wound care services, more providers are finding themselves the target of sudden, high-stakes audits. What begins as a seemingly routine records request can quickly snowball into a full-blown investigation with significant financial and regulatory consequences. For wound care providers, the complexity of coding, documentation, and coverage rules means even well-intentioned practices can face significant financial and reputational exposure.

At Health Law Alliance, we’ve guided countless providers through these exact scenarios. This overview explains what typically happens during a wound care audit, and why it is critical to navigate the process alongside experienced counsel.

How a Wound Care Audit Usually Begins

Most audits start quietly. A payor—Medicare, a Unified Program Integrity Contractor (“UPIC”), a commercial plan, or even a subcontracted auditor—issues a request for medical records tied to wound care services. Often, wound care audits focus on a select number of procedures and services, including wound debridements, flap and graft repairs, and ongoing chronic wound management encounters.

The initial request may be small at first, but it rarely stays that way. Once auditors review the initial sample, they often broaden the scope, widening the date range to review additional claims data or expanding into other types of wound care claims.

Engaging counsel at this stage is critical to minimize risk to your practice. Providers without counsel often provide incomplete records or rely on their billing staff to submit an informal response without appropriate oversight, unaware that the language used, documents provided, or explanations offered at this stage become the foundation for the auditor’s conclusions. Early mistakes can’t be undone later. Involving experienced health care counsel from the outset ensures responses are strategic, consistent, and professional, protecting you from inadvertently providing information that opens the door to a far broader investigation.

What Auditors Look For

Wound care billing is one of the most technically demanding areas in health care reimbursement. Auditors typically focus on:

• whether procedures were coded at the correct complexity level;
• whether documentation supports the wound size, depth, or technique used;
• whether treatments were medically necessary according to payor rules;
• whether services were billed separately when they should have been bundled; and
• whether utilization patterns deviate from “expected norms.”

These determinations are highly subjective. At this stage, auditors closely evaluate your documentation, reinterpreting provider judgment, clinical documentation, or CPT guidance months (or even years) after the fact and without additional context. Even small discrepancies in a patient’s chart can be construed as improper billing.

From our experience as former federal prosecutors and government health care attorneys, we know that wound care audits are among the most aggressive, allowing auditors to challenge both coding and medical necessity. Without the right support, a wound care audit can easily open a practice up to significant financial and legal consequences.

What Providers Can Expect as the Audit Escalates

A wound care audit typically progresses through several stages:

1. Increasingly broad documentation requests

After an initial request for documents, auditors rarely stop there. Additional document requests may include patient charts, operative notes, photos, supply logs, E/M documentation, and provider credentials.

2. Technical challenges to coding and clinical judgment

Auditors frequently dispute providers’ choices in selecting services for patients, such as flap versus linear repair, levels of debridement, or the necessity of biologics, often using hindsight and internal policies that providers have never seen.

3. Extrapolated overpayment demands

This is where the real risk lies. If auditors determine that a sample of claims is “improper,” they may extrapolate that error rate across hundreds or thousands of claims—turning what was once a small initial review into a six- or seven-figure liability.

4. Referral for further investigation

If auditors believe there are patterns of upcoding or lack of medical necessity across claims, cases are routinely referred to CMS, UPICs, or even the Department of Justice. A referral to one of these entities not only means massive financial consequences but also carries a significant risk of civil or criminal charges.

Why Early Legal Representation Matters

By the time an audit begins, payors have already armed themselves with data analytics, internal policies, and coding interpretations that heavily favor the government. Providers who respond on their own or rely solely on their billing staff often unintentionally make the situation worse.

Health Law Alliance brings the experience of former prosecutors and government insiders who understand precisely how these audits unfold. We know what auditors look for, how they interpret documentation, and what arguments actually move the needle. Our involvement early in the process can prevent escalation, narrow the scope of auditors’ document requests, and protect providers from common missteps that often result in broader investigations.

The Bottom Line

A wound care audit is not a routine administrative matter: it’s an audit that can threaten the financial health of your practice and expose you to serious regulatory risk. The rules are complex, the scrutiny is intense, and the consequences are real.

If your practice has received an audit notice—or if you suspect one may be coming—don’t go it alone. Health Law Alliance stands ready to guide you through the process, protect your practice, and prepare a strategy-driven response at every stage.

Don’t wait until your practice is under threat. Contact us today for a free consultation and learn how we can help.