Who is asking, and why
Medicare relies on several kinds of private contractors to review claims, and the name on the letter tells you something about the stakes. Some reviews are routine checks on billing patterns, others look for improper payments to recover, and some focus on potential fraud. In certain reviews, errors found in a sample can be extrapolated across a much larger set of claims, which changes the size of the problem considerably. Medicare Advantage plans, which are private insurers, run their own audits under their own contracts. Reading the letter carefully, including the response deadline it sets, is the first step.
Documentation is the defense
Medicare compliance in practice comes down to whether the medical record supports what was billed, including medical necessity and the level of service. Orders, signatures, progress notes, and any required certifications are checked against payment rules that change regularly. Records should be produced as they exist, because adding to an old note in response to an audit can create a far more serious problem than the original claim. If the documentation is incomplete, it is better to understand that before it is submitted. We help organize the response so that each claim is supported in a way a reviewer can follow.
Appeals and repayment
When a contractor finds an overpayment, Medicare offers a multi-level appeal process, and each level carries its own filing deadline. Some of those deadlines are short, and appealing at an early level within a particular window can affect whether recoupment of the money is paused. Separately, when a provider identifies an overpayment on its own, federal law generally requires reporting and returning it within a set period. In an initial consultation we look at the letter, the claims involved, and the documentation, and discuss whether to appeal, repay, or do some of each. We also consider whether the issue points to a broader billing problem worth reviewing.
