Nothing stops an audit. Something determines what it finds.
The Recovery Audit Contractor programme pays private auditing firms to examine provider records and claims in all fifty states. Any provider billing fee-for-service Medicare, Medicaid or commercial plans is in scope. It has identified billions of dollars in overpayments, which is precisely why it continues.
What they look for
Three indicators, in this order:
- Coding inconsistencies — the same service coded differently across encounters or providers.
- Documentation that does not support medical necessity for the services billed.
- Overpayments or underpayments to the provider.
Why it is worth being early
If an audit finds any of the three, you repay the overpayment with interest. Appeals in this programme have not historically been a reliable route out. And the auditors are entitled to keep returning — on a rolling cycle, roughly every 45 days — until they find nothing further.
That last part is the one practices underestimate. A single adverse finding does not end with the repayment; it begins a recurring examination that consumes staff time indefinitely.
What MD Audit Shield does
- Reviews 50 records selected at random from your billing, looking for improper coding and Medicare or Medicaid non-compliance.
- Specifies exactly what corrective action each finding requires.
- Performs the necessary changes to bring you into compliance rather than handing you a list.
- Stands with you if an audit does arrive — you are not left to explain your own records alone.
This is a self-audit run on your terms, in advance, with time to fix what it finds. The alternative is the same examination conducted by someone whose fee depends on finding something.
- Fee-for-service Medicare
- Medicaid
- Commercial insurance programmes
If you bill any of the above, you are auditable. Practice size is not a defence, and neither is having never been audited before.
Related
Coding consistency is the first thing an audit tests, so the coding service and this one solve overlapping problems. The free code review is a reasonable first look at your exposure and costs nothing.