What Triggers a Medicare Audit of a Medical Practice?

 Posted on March 08, 2026 in Professional License Defense

A Medicare audit doesn't always mean your practice did something wrong. Many audited providers are honest practices that ran into billing or recordkeeping problems, not fraud. Still, receiving an audit notice is serious, and how you respond can make a big difference in what happens next.

If your practice has received an audit notice in 2026, or if you want to understand what puts a practice at risk, a Peoria, IL professional license defense lawyer can help you figure out where you stand.

What Is a Medicare Audit?

A Medicare audit is a formal review of your billing records, patient charts, and claim submissions. Auditors want to confirm that the services you billed for were actually provided, medically necessary, and properly documented. The review may cover a handful of claims or hundreds, depending on the type of audit and what triggered it.

Types of Medicare Audits

There are a few different types of Medicare audits. Recovery Audit Contractors, known as RACs, look for overpayments and underpayments in past claims. The Targeted Probe and Educate program (TPE) focuses on providers with higher-than-average claim error rates and works with them to correct problems. The Office of Inspector General (OIG) conducts its own investigations, often when suspected fraud is involved. Knowing which type of audit you're facing is the first step in responding the right way.

What Are the Most Common Triggers for a Medicare Audit?

Medicare auditors don't select practices at random. They use data, complaints, and billing patterns to decide where to look.

The most common reasons a practice gets flagged include:

• Billing rates or code patterns that look different from similar practices in your area
• A high volume of claims for expensive procedures or specialty services
• Documentation that doesn't match the submitted billing codes
• Services billed that Medicare doesn't consider medically necessary
• Complaints from patients, former employees, or other providers
• Inconsistent coding among providers within a group practice
• Telehealth claims that lack proper documentation or don't meet coverage requirements

None of these triggers automatically means fraud. Many come from honest mistakes made by billing staff or gaps in how records are kept.

What Happens After an Audit Is Triggered?

Once your practice is selected for review, you'll receive a records request. You'll need to submit patient charts, billing records, and any other documentation that supports the claims in question. Auditors will then review those records and decide whether the claims were accurate.

If they find problems, you may be asked to repay overpayments. In more serious cases, the findings can be referred to the OIG or the Department of Justice for further investigation under the False Claims Act, 31 U.S.C. § 3729, which makes it illegal to knowingly submit false or fraudulent claims to a federal health care program and carries significant civil penalties.

Can a Medicare Audit Affect Your Medical License?

If an audit uncovers patterns that suggest fraud, repeated billing violations, or gross negligence, the matter can be referred to the Illinois Department of Financial and Professional Regulation (IDFPR). That agency oversees medical licenses in Illinois, and an investigation at that level is completely separate from the Medicare process. For a physician who has spent years building a practice and caring for patients, this can be a very stressful prospect.

The penalties at that level can include suspension or revocation of your license to practice. What starts as a billing review can become a fight for your entire career, which is why how you respond matters so much.

What Should You Do If Your Practice Is Audited?

Don't wait to get help. The records you submit and the way you respond in the early stages can shape the entire outcome. Consider a few things to keep in mind:

• Don't submit records in a hurry. Review everything carefully before it goes to the auditor.
• Keep copies of everything you send.
• Don't make changes to records after an audit has been initiated.
• Contact a professional license defense attorney before you respond to any formal inquiry.

Schedule a Free Consultation With Our St. Louis Area, IL Medicare Repayment Attorney

If your medical practice is facing a Medicare audit or if it has escalated into a licensing investigation, you need someone who understands both sides of the process. Attorney Joseph Bogdan brings over 20 years of experience to cases like yours. As a registered pharmacist and a licensed attorney, he understands how medical billing, documentation, and regulatory compliance all connect. Call The Law Offices of Joseph J. Bogdan, Inc. at 630-310-1267 today to schedule a free consultation with our Peoria, IL professional license defense lawyer.