Protecting Your Practice: How to Avoid Common Pitfalls in Medicare and Medi-Cal Audits

As a healthcare provider in California, your practice is subject to strict oversight from state and federal government agencies that administer Medicare and Medi-Cal. Routine audits are an integral part of these programs to ensure compliance and prevent fraud. However, even honest mistakes can lead to severe consequences, including fines, recoupments, and even criminal charges.

Below we discuss common pitfalls when it comes to audits and how to avoid them. For help protecting your practice and maintaining your reputation in Los Angeles and statewide, contact the Law Offices of Art Kalantar for help from an experienced and successful California Medicare audit lawyer.

Common Pitfalls in Medicare and Medi-Cal Audits (and how to avoid them)

1. Incomplete or Inaccurate Documentation

One of the most frequent causes of audit issues is inadequate record-keeping. Auditors closely scrutinize patient records, billing details, and treatment plans. If documentation is incomplete, inconsistent, or missing necessary details, auditors may determine that a claim is not supported, leading to denials or recoupments.

How to Avoid It: Ensure that all patient records are thorough and updated in real time. Include all necessary elements such as diagnosis, treatment rationale, and physician signatures. Conduct regular internal audits to check for gaps in documentation.

2. Upcoding and Unbundling Errors

Billing mistakes, such as using incorrect codes (upcoding) or improperly separating services that should be billed together (unbundling), can trigger audits and penalties. These errors may be interpreted as fraudulent billing practices, even if they were unintentional.

How to Avoid It: Train billing staff regularly on coding guidelines. Use coding software to flag potential errors before claims are submitted. Review claims before submission to ensure accuracy.

3. Lack of Medical Necessity

Claims that do not sufficiently demonstrate medical necessity are a red flag for auditors. Medicare and Medi-Cal only cover services deemed medically necessary, and vague or generic justifications can result in denials.

How to Avoid It: Clearly document the need for each service provided. Align patient records with accepted clinical guidelines. Use detailed physician notes to support claims of medical necessity.

4. Improper Use of Provider Numbers

Billing under an incorrect or inactive provider number is another common audit pitfall. This often happens when providers fail to update their credentials or when services are improperly billed under a supervising physician rather than the treating provider.

How to Avoid It: Keep provider enrollment information current. Verify that claims reflect the correct rendering provider. Regularly update staff on any changes in provider credentialing requirements.

5. Failing to Respond to Audit Requests

Ignoring or delaying responses to audit requests can escalate issues quickly. Non-responsiveness may be perceived as an attempt to conceal fraudulent activity, leading to more severe penalties.

How to Avoid It: Designate a compliance officer or legal representative to handle audit communications. Respond to audit requests promptly and provide requested documentation in an organized manner. Consult a healthcare defense attorney if an audit request appears complex or excessive.

Best Practices to Protect Your Practice

• Implement a Compliance Program: A well-structured compliance program can help prevent errors and demonstrate your commitment to lawful billing practices.
• Regular Internal Audits: Conducting self-audits can identify and address potential issues before they become a problem during an official audit.
• Legal Consultation: Working with an experienced healthcare defense attorney can provide guidance on best practices and ensure you are prepared for audits.
• Continuous Education: Keep up with changing Medicare and Medi-Cal regulations to ensure compliance with current standards.

What to Do If You Are Facing an Audit

If your practice is under audit, take immediate steps to mitigate potential risks:

• Do not ignore the audit notice. Respond promptly and professionally.
• Gather and review all requested documentation. Ensure accuracy and completeness before submission.
• Seek legal representation. A healthcare defense attorney can help protect your rights and negotiate on your behalf.
• Cooperate with auditors. While being cooperative can be helpful, avoid volunteering unnecessary information that could be misinterpreted.

Contact the Law Offices of Art Kalantar for Help With Medicare and Medi-Cal Audits in Los Angeles and Throughout California

Medicare and Medi-Cal audits can be stressful, but proactive compliance measures can significantly reduce the risk of penalties. By maintaining accurate records, following billing regulations, and seeking legal guidance when necessary, healthcare providers can safeguard their practices from common audit pitfalls. If you are facing an audit or need help strengthening your compliance efforts in California, contact the Law Offices of Art Kalantar in Los Angeles today for expert legal assistance.