Most medical providers, including doctor’s offices, hospitals, pharmacies, and other types of medical professionals, provide services to patients and accept payments through Medicare or Medicaid. Providers must meet a variety of requirements when doing so, and the Centers for Medicare and Medicaid Services (CMS) is tasked with ensuring that providers are in compliance. CMS may conduct audits of providers based on billing irregularities, issues related to record-keeping, or other concerns about potential noncompliance. During these types of audits, providers will want to understand the process that will be followed and the requirements they must meet. Failure to comply with CMS requirements or cooperate during an audit could result in the provider being excluded from providing services through Medicare or Medicaid.
Steps Followed in a CMS Audit
The Medicare/Medicaid audit process has four phases:
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Engagement and universe submission - Auditors will notify a provider of an audit and send an engagement letter that identifies the information that will be requested. This information will take the form of “universes,” which consist of data sets from a health plan, including Part C Organization Determinations, Appeals, and Grievances (ODAG) and Part D Coverage Determinations, Appeals, and Grievances (CDAG). After the provider submits the requested universes, auditors will assess the data provided and determine whether any other information is necessary. This phase will last six weeks.
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