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Understanding Medicare Recovery Audits and Steps to Prevent Them


Medicare recovery audits target healthcare providers, facilities, and organizations that submit reimbursement claims under the Medicare Fee-for-Service (FFS) program. In other words, as the Centers for Medicare and Medicaid Services (CMS) stated, “If you bill FFS programs, your claim will be subject to review by the Recovery Auditors.”

You might have read our post on Recovery Audit Contractor (RAC) Audits, but there’s more updated information to share on the Medicare Recovery Audit program, including how to prevent your practice from receiving audits. 

What Are Medicare Recovery Audits?

Medicare recovery audits are conducted by third-party auditors hired by the government to thoroughly review healthcare payment claims submitted to Medicare for reimbursement. These audits aim to ensure the claims are legitimate and not fraudulent. 

If the auditors find suspicious activity or improper payments, they will allow your healthcare practice to address these concerns. However, before the reimbursement process can proceed, the CMS must approve that the identified concerns or improper payment determinations have indeed met the standards set by the government. If the CMS does not approve it, your healthcare practice could be denied reimbursement for the specific claim. 

What Do I Do If I Receive a Recovery Audit?

As a healthcare provider, you have four options for how to respond if you receive a Medicare recovery audit:

  1. Pay it right away. If you agree with the audit, you can settle the identified discrepancies by making a payment via check. This means that you acknowledge the audit findings and wish to resolve the issue immediately by simply making the required payment. 
  2. Request or apply for an extended payment plan. If your healthcare practice is struggling financially and can’t afford to pay the entire amount at once, you can ask for a payment plan. If approved, you can pay the money in smaller installments over time.
  3. File an appeal. If you think there’s an error and strongly disagree with the recovery auditor’s determination, you can present additional information, evidence, and compelling arguments to dispute the audit findings. If you are successful, the Medicare recovery audit will hopefully be reconsidered, modified, or overturned.  

Steps to Prevent Medicare Recovery Audits

The CMS suggests certain steps you can take to avoid Medicare recovery audits in the first place, since such audits can be risky for your healthcare practice. 

1. Comply with Medicare Rules

Before submitting a reimbursement claim, you want to make sure it doesn’t consist of improper payments. This means implementing regular internal assessments to check that your healthcare practice is abiding by Medicare guidelines.

Assigning this task to a team or employee can help emphasize the importance of following Medicare rules consistently. You can also add a monthly team meeting to the calendar to discuss previously denied claims and corrective actions you could implement moving forward.

Keeping a record of past errors helps prevent making the same mistakes again, ensuring the accuracy of your statements. Such tips could be highly beneficial to the healthcare practice as a whole.

2. Connect with Your Recovery Auditor

Before receiving a recovery audit, you want to establish clear lines of communication with the recovery auditor. This means providing them with the exact address and contact information for your healthcare practice so that any correspondence, such as medical record request letters, reaches the right person. 

After submitting a claim, you should confirm its receipt by checking its status. You can do this by contacting the recovery auditor or visiting the recovery audit program’s website. If there are uncertainties or delays in the processing of your claim, be proactive by reaching out to the recovery auditor as soon as possible. 

3. Appeal When Necessary

Keep in mind that the recovery audit programs’ discussion period differs from the actual appeal process. The discussion period, as explained earlier, is the phase of the recovery audit process when you can talk with the auditors about their findings and raise any concerns you have. The appeals process occurs only after you’ve officially received the Medicare recovery audit and your disagreement with the determination strongly persists.

To file an appeal, initiate the formal appeals process before the 120th day after receiving the demand letter with the audit findings. Our healthcare law lawyers can guide you through the process. 

Contact a Healthcare Attorney Today

If you are subject to a medicare recovery audit, it is crucial to hire an experienced healthcare lawyer well-versed in this subject. Our healthcare practice offers a team of knowledgeable and experienced attorneys who can guide you through the process, advocate for you, and refute fraud claims on your behalf. Contact us at (310) 444-5244 or fill out the form on our website today to connect with a healthcare practice attorney.