At Varghese & Associates, P.C., we understand that receiving notice of a Medicare audit can trigger significant anxiety for healthcare providers. As dedicated Medicare audit lawyers, we offer comprehensive representation throughout all stages of the audit process, protecting your practice, reputation, and financial stability.

What Are Medicare Audits?

Medicare conducts various types of audits through different contractors to identify improper payments, billing irregularities, and potential fraud. These audits range from routine reviews to targeted investigations that can escalate into serious legal matters if not properly addressed.

How Our Medicare Audit Lawyers Can Protect Your Rights

Our Medicare fraud defense lawyers implement strategic approaches to shield healthcare providers from the potentially devastating consequences of Medicare audits, ensuring your rights are protected throughout the process.

• Immediate intervention: Our Medicare audit lawyers engage from the moment you receive notice of an audit, taking control of communications and ensuring no damaging admissions occur during preliminary interactions.
• Strategic documentation review: Our Medicare audit lawyers thoroughly analyze medical records and billing documentation before submission to identify vulnerabilities and strengthen supportive evidence for contested claims.
• Response preparation: Our Medicare audit lawyers crafts comprehensive written responses that effectively address auditor concerns while establishing solid legal positions for potential appeals.
• Statistical sampling challenges: Our Medicare audit lawyers scrutinize extrapolation methodologies used by auditors, often identifying statistical errors that significantly reduce alleged overpayment amounts.
• Expert coordination: Our Medicare audit lawyers collaborate with coding specialists, medical consultants, and statistical experts to challenge technical aspects of audit findings.
• Appeal representation: Our Medicare audit lawyers navigate the complex five-level Medicare appeals process, developing compelling arguments at each stage and ensuring compliance with critical deadlines.
• Administrative hearing advocacy: Our Medicare audit lawyers provide powerful representation at Administrative Law Judge hearings, where providers have the greatest opportunity to present their case directly.
• Settlement negotiations: When appropriate, our Medicare audit lawyers leverage our experience to negotiate favorable resolutions that minimize financial impact and avoid program exclusion.
• Audit-triggered investigation defense: If audits escalate to fraud investigations, our Medicare audit lawyers provide seamless representation addressing both administrative and potential criminal aspects.

At Varghese & Associates, P.C., we understand that effective Medicare audit requires both healthcare regulatory knowledge and strategic advocacy skills. Our Medicare audit lawyers combine these capabilities to protect your practice, reputation, and professional future throughout the audit process.

Who Performs Medicare Audits?

At Varghese & Associates, P.C., our Medicare audit lawyers regularly represent healthcare providers facing audits conducted by various contractors engaged by the Centers for Medicare and Medicaid Services (CMS). Understanding which entity is conducting your audit is crucial for developing an effective defense strategy.

• Medicare Administrative Contractors (MACs): Regional contractors responsible for processing Medicare claims who conduct routine audits focusing on coding accuracy, documentation completeness, and basic compliance with Medicare rules.
• Recovery Audit Contractors (RACs): Private companies working on contingency fees that identify and recover improper Medicare payments, incentivized by keeping a percentage of funds recovered from providers.
• Unified Program Integrity Contractors (UPICs): Specialized investigators who focus on identifying potential fraud, waste, and abuse through sophisticated data analysis, often conducting the most aggressive forms of Medicare audits.
• Supplemental Medical Review Contractors (SMRCs): Entities that conduct targeted reviews of specific issues identified by CMS as problematic, frequently examining medical necessity and compliance with coverage criteria.
• Comprehensive Error Rate Testing (CERT) contractors: Reviewers who select random samples of claims to measure improper payment rates across the Medicare program, identifying systemic billing issues.
• Office of Inspector General (OIG): Federal investigators conducting audits as part of their oversight mission, often targeting specific providers or practices identified through fraud risk assessments or whistleblower complaints.
• Quality Improvement Organizations (QIOs): Entities focused on reviewing quality of care issues, including medical necessity determinations and appropriate care settings for Medicare beneficiaries.
• Medicaid Fraud Control Units (MFCUs): State-level investigators who may conduct joint audits with Medicare contractors when providers bill both programs, increasing complexity and potential exposure.

At Varghese & Associates, P.C., our Medicare audit lawyers develop strategic responses tailored to the specific contractor conducting your audit, leveraging our understanding of each entity's procedures, authority limitations, and typical approaches to maximize your chances of a favorable outcome.

Common Types of Medicare Audits

As Medicare audit lawyers, we regularly assist healthcare providers facing various types of audits, each with distinct procedures and potential consequences. Understanding the specific audit type you're facing is crucial for developing an effective defense strategy.

• Medicare Administrative Contractor (MAC) audits: Initial claim reviews conducted by regional contractors who process Medicare payments, typically focusing on documentation completeness and compliance with basic billing requirements.
• Recovery Audit Contractor (RAC) audits: Reviews conducted by private contractors paid on contingency for identifying and recovering improper Medicare payments, often targeting high-volume procedures or billing patterns that deviate from norms.
• Comprehensive Error Rate Testing (CERT) audits: Random reviews measuring improper payment rates across the Medicare program, which may not target specific providers but can still result in repayment demands.
• Zone Program Integrity Contractor (ZPIC) audits: Targeted investigations focusing on potential fraud, waste, and abuse that typically involve extensive documentation requests and may lead to payment suspensions or referrals for criminal investigation.
• Unified Program Integrity Contractor (UPIC) audits: Enhanced integrity reviews that consolidate the functions of ZPICs and other contractors, with broad authority to investigate suspected fraud across multiple Medicare programs.
• Supplemental Medical Review Contractor (SMRC) audits: Focused reviews of specific billing issues identified by CMS as problematic, often examining medical necessity and compliance with coverage criteria.
• Office of Inspector General (OIG) audits: High-level investigations conducted as part of the OIG's oversight mission, which often indicate serious compliance concerns and can lead to significant financial penalties.

At Varghese & Associates, P.C., our Medicare audit lawyers develop tailored defense strategies based on the specific audit type you face, addressing the unique procedural requirements and potential risks associated with each contractor's review process.

Warning Signs That May Trigger a Medicare Audit

As Medicare audit lawyers, we've observed that certain billing patterns and practice characteristics frequently attract scrutiny from Medicare's sophisticated fraud detection systems and audit contractors. Understanding these risk factors can help you implement preventive measures before receiving an audit notice.

• Outlier billing patterns: Submitting claims with frequencies that significantly deviate from peers in your specialty and geographic region often triggers automated review flags in Medicare's data analysis systems.
• High utilization of specific codes: Disproportionate use of certain procedure codes, particularly high-reimbursement services or those historically prone to abuse, frequently attracts auditor attention.
• Spike in billing volume: Sudden, substantial increases in Medicare billing without corresponding growth in practice size or patient population raises immediate red flags.
• Upcoding indicators: Regular billing of higher-level services (such as consistently using level 4-5 E/M codes) compared to specialty norms often leads to targeted reviews.
• Missing documentation: Previous instances of insufficient documentation or signatures on submitted claims may place your practice on high-risk lists for future audits.
• Pattern of claim denials: An unusually high percentage of denied claims suggests potential compliance issues that frequently trigger more comprehensive audits.
• Whistleblower complaints: Reports from current or former employees, patients, or competitors about potential billing irregularities often initiate focused investigations.
• Patient complaints: Beneficiary questions about services appearing on their Medicare Summary Notices that they don't recall receiving frequently launch audit inquiries.
• OIG focus areas: Providing services specifically identified in the OIG's annual Work Plan as targeted review areas substantially increases audit probability.

At Varghese & Associates, P.C., our Medicare audit lawyers help providers assess their compliance risks, implement preventive measures, and develop robust documentation practices that can withstand scrutiny when audits occur.

Who Faces Medicare Audits the Most?

As Medicare audit lawyers, we regularly observe that certain healthcare providers face disproportionate audit scrutiny based on their specialty, billing patterns, or practice characteristics. Understanding these risk factors can help you assess your own audit vulnerability and implement appropriate preventive measures.

• Home health agencies: These providers experience particularly intense audit scrutiny due to historical fraud concerns, with many facing multiple simultaneous audits from different contractors.
• Durable medical equipment (DME) suppliers: Medicare aggressively targets DME providers, especially those billing for high-cost items like power mobility devices, orthotics, and respiratory equipment.
• Pain management specialists: Physicians prescribing controlled substances and performing interventional procedures face heightened audit attention, particularly regarding medical necessity documentation.
• Skilled nursing facilities: These providers undergo frequent reviews focusing on therapy utilization patterns and documentation supporting higher RUG categories.
• Behavioral health providers: Mental health professionals face growing audit scrutiny regarding proper documentation of psychotherapy sessions and appropriate use of time-based billing codes.
• High-utilizing physicians: Any provider whose billing volume or pattern significantly exceeds peer averages faces substantially increased audit risk regardless of specialty.
• Recently audited practices: Providers with prior adverse audit findings typically experience repeat audits within 1-3 years, creating a cycle of ongoing scrutiny.
• New providers: Practices newly enrolled in Medicare often face early audits as the program assesses their compliance with billing requirements.

At Varghese & Associates, P.C., our Medicare audit defense lawyers work with providers across these high-risk categories to implement robust documentation practices, effective compliance programs, and strategic responses when audits occur despite preventive efforts.

The Medicare Audit Process

At Varghese & Associates, P.C., our Medicare audit lawyers guide healthcare providers through each stage of the Medicare audit process, from initial notification to final resolution.

• Audit notification: Medicare contractors initiate the process by sending written requests for specific patient records, typically giving providers 30-45 days to respond with complete documentation.
• Documentation submission: Providers must gather and submit all requested medical records, billing information, and supporting documentation within the specified timeframe to avoid automatic denials.
• Review phase: Auditors examine submitted documentation to determine compliance with Medicare requirements, medical necessity criteria, and proper coding standards.
• Preliminary findings: After completing their review, auditors issue an initial determination letter outlining any identified improper payments and explaining the basis for their findings.
• Overpayment demand: If improper payments are identified, Medicare issues a formal demand letter requiring repayment, often with interest, within a specified timeframe.
• Extrapolation calculation: For statistical audits, contractors may extrapolate findings from a sample to your entire claims universe, potentially multiplying the alleged overpayment amount significantly.
• Rebuttal opportunity: Providers typically have 15 days to submit a rebuttal statement addressing preliminary findings before formal recoupment begins.
• Payment suspension: In cases suggesting potential fraud or significant billing irregularities, Medicare may suspend all payments during the investigation period.
• Appeals process: Providers disagreeing with audit findings can pursue a five-level appeal process, beginning with redetermination and potentially concluding in federal court.

At Varghese & Associates, P.C., our Medicare audit lawyers provide strategic representation at each stage of this complex process, protecting your rights and developing effective responses that minimize financial impact and preserve your ability to continue serving Medicare patients.

The Risks of Medicare Audits

At Varghese & Associates, P.C., our Medicare audit defense lawyers understand that Medicare audits pose significant risks beyond immediate financial concerns, potentially threatening the very survival of your healthcare practice.

• Substantial repayment demands: Audit findings often result in significant overpayment determinations, particularly when statistical extrapolation multiplies identified errors across your entire Medicare billing history.
• Extrapolated damages: When auditors review a small sample of claims and find errors, they may apply the error rate to all similar claims for the review period, potentially turning a few thousand dollars in questionable claims into hundreds of thousands in demands.
• Cash flow disruption: During audits, Medicare may suspend ongoing payments for new claims, creating immediate financial strain even before final determinations are made.
• Pre-payment review: Unfavorable audit findings frequently result in providers being placed on pre-payment review, where all future claims require manual review before payment, significantly delaying reimbursements.
• Increased future scrutiny: Once identified in one audit, providers often face heightened scrutiny and additional audits from multiple contractors in subsequent years.
• Referrals to law enforcement: Audits suggesting potential fraud may trigger referrals to the Department of Justice or OIG for criminal investigation and prosecution.
• Program exclusion: Serious compliance violations identified during audits can lead to exclusion from participation in Medicare, Medicaid, and all federal healthcare programs.
• Professional licensing consequences: Audit findings implying improper billing practices may prompt state licensing board investigations and potential disciplinary actions.
• Reputational damage: Public disclosure of audit results can damage professional standing and patient confidence, affecting practice viability even beyond Medicare participation.

At Varghese & Associates, P.C., our Medicare audit defense lawyers work diligently to mitigate these risks through strategic representation, comprehensive documentation review, and aggressive advocacy throughout the audit and appeals process.

What To Do If Facing a Medicare Audit

When your practice receives notice of a Medicare audit, taking prompt and strategic action is essential to protect your rights and achieve the most favorable outcome possible. Our Medicare audit defense lawyers recommend following these critical steps.

• Contact a Medicare audit defense lawyer immediately: Secure legal representation before responding to the audit notice or communicating with auditors to ensure your rights are protected from the outset.
• Preserve all documentation: Implement a litigation hold to safeguard all potentially relevant medical records, billing information, communication records, and compliance materials.
• Review the audit request carefully: Identify exactly what records are being requested, which claims are under review, and all applicable deadlines for response.
• Conduct an internal assessment: Work with your Medicare audit defense lawyer to review the targeted claims and documentation before submission to identify potential vulnerabilities.
• Prepare comprehensive responses: Submit complete, well-organized documentation packages that include all supporting materials necessary to justify the services billed.
• Maintain communication logs: Document all interactions with auditors, including dates, times, individuals involved, and the substance of each communication.
• Consider statistical implications: If the audit involves sampling, consult with statistical experts to evaluate methodological soundness and potential extrapolation impacts.
• Prepare for financial contingencies: Develop strategies to manage potential cash flow disruptions if payment suspensions or substantial recoupment demands occur.
• Evaluate appeal options: Review preliminary findings carefully with your Medicare audit defense lawyer to identify viable grounds for appeal before deadlines expire.

At Varghese & Associates, P.C., our Medicare audit defense lawyers provide strategic guidance through each of these steps, working to minimize financial impact while protecting your ability to continue serving Medicare patients.

Why Choose Varghese & Associates, P.C. for Medicare Audit Defense

When facing a Medicare audit, your choice of legal representation significantly impacts the outcome. Our Medicare audit defense lawyers offer:

• Healthcare Regulatory Knowledge: Our Medicare audit lawyers maintain detailed understanding of Medicare regulations, coding requirements, and documentation standards.
• Strategic Approach: Our Medicare audit lawyers develop defense strategies tailored to your specific circumstances, audit type, and potential exposure.
• Federal Administrative Experience: Our healthcare fraud defense lawyers possess extensive experience navigating the complex Medicare appeals system.
• Result-Oriented Representation: We focus on achieving tangible results that protect your practice, finances, and professional standing.
• Clear Communication: Throughout the audit process, we provide clear explanations of your options, potential outcomes, and recommended strategies.

Contact Our Medicare Audit Defense Lawyers

If you've received notice of a Medicare audit or believe you may be under review, contact Varghese & Associates, P.C. today for a confidential consultation. Our Medicare audit defense lawyers will evaluate your situation, explain your options, and begin developing a strategic defense approach tailored to your specific circumstances.

Don't face Medicare auditors alone. With the right legal representation, you can navigate the audit process effectively while protecting your practice and professional future.