The federal machinery behind a Medicare case
Medicare is a federal program, so a Medicare fraud matter involves federal agencies at every turn. CMS works through private contractors that audit claims and look for fraud patterns, and those contractors can recommend payment suspensions or refer cases onward. The HHS Office of Inspector General investigates and can seek exclusion from federal health programs, while the Justice Department handles civil cases under the False Claims Act as well as criminal prosecutions. Many cases start with a whistleblower, often a current or former employee, who files a sealed qui tam complaint that the provider does not see for some time. A single set of claims can therefore produce administrative, civil, and criminal consequences.
Responding to the first request
An audit letter or records request carries deadlines, and missing them can lead to denials or an overpayment demand that has been extrapolated from a sample. Keep the original request and its envelope, gather the specific records asked for, and respond completely without adding to or rewriting documentation after the fact. Preserve emails, billing system data, and compliance records, and suspend routine deletion. If you also see Medicare Advantage patients, the plans may be auditing you under their own contracts. Talk to counsel before anyone in the practice sits for an interview with investigators.
Deciding the overall approach
We begin by identifying every track that is open or likely: an audit, a payment suspension, a civil investigative demand, a subpoena, or contact from criminal agents. We look at whether the issue is a coding or documentation dispute that belongs in the appeals process, or whether intent is being alleged. We also consider whether an overpayment has already been identified that should be reported and returned, which carries obligations of its own. Then we discuss how to communicate with the government, how to keep the practice operating, and whether employees need separate counsel.
