A CMS Medicare Advantage audit is a process used by the Centers for Medicare and Medicaid Services (CMS) to ensure that Medicare Advantage (MA) plans, also known as Medicare Part C, are complying with regulations and standards set by the CMS. The process includes several stages, including notification of the audit, preparation, on-site review, audit findings, and potential repayment or appeals.
Here’s a general overview of what to expect during a CMS audit:
- Notification of Audit: The provider will be notified by the CMS of the audit, and will be given a specific timeframe in which to prepare for the audit.
- Preparation: The provider should review their billing and medical records to ensure they are accurate and in compliance with government regulations. They should also review the CMS audit protocol and gather any supporting documentation that may be needed during the audit.
- On-site Audit: A CMS representative will conduct an on-site audit of the provider’s billing and medical records. The audit may last several days, and the provider should be prepared to answer any questions and provide any necessary documentation.
- Audit Findings: After the audit, the CMS representative will provide a report of their findings. If any errors or discrepancies are found, the provider will be given an opportunity to correct them.
- Payment Recoupment: If the audit finds that the provider has overbilled the government, they may be required to repay the overbilled amount.
- Appeals: If the provider disagrees with the audit findings, they have the right to appeal the decision.
It is important to note that the CMS audit process can be stressful and time-consuming, but by following the guidelines and providing accurate and complete information, providers can minimize their risk of overpayment recoupment and negative findings.
It’s always a good idea to be proactive and conduct regular internal reviews and compliance audits to identify and correct any errors or non-compliance issues before an official CMS audit takes place.
In summary, a CMS audit is a process used by the government to ensure that healthcare providers and suppliers are complying with Medicare and Medicaid regulations. During an audit, a CMS representative will review a provider’s billing and medical records to ensure they are accurate and in compliance with government regulations. Providers should be prepared to answer any questions and provide any necessary documentation.