Preparing for a CMS Audit: What to Anticipate

  • Written by Ashley Mark
  • Tuesday 31st January 2023
Preparing for a CMS Audit: What to Anticipate VLMS Healthcare

Centers for Medicare and Medicaid Services (CMS) focus on a seamless flow of healthcare services. It uses a process known as CMS audit for ensuring that medicare advantage plans are complying with guidelines and standards set by CMS. This process comprises various stages including notification of the audit, composing, on-site review, audit results, and significant repayment and appeals. 

Let’s discuss some points about what to expect from a CMS audit:

  • Notification of the audit- The CMS of audit will notify the healthcare provider about the audit and the proper time will be given to prepare and keep everything ready. 
  • Preparation- Healthcare providers have to review and check their medical billing and records to make sure they are accurate and in compliance with government guidelines. In addition, they should evaluate the CMS audit procedure and obtain any necessary supporting documents.
  • On-site audit- An on-site audit of the provider’s medical billing and records is done by CMS representatives. The provider should be able to answer any questions or the presentation of documentation that can be asked by a CMS representative at any time. The audit may last for a week as well. 
  • Audit findings- The CMS representative will deliver a report on their conclusions following the audit. If any mistakes or inconsistencies are discovered, the provider will be given a chance to make things right.
  • Recoupment of payment- If the audit reveals that the provider overcharged the government, they would have to pay back the excess.
  • Appeals- The provider has the opportunity to challenge the judgment if they don't agree with the audit results.

It is true that CMS audits can be stressful and time-consuming. However, with the right documentation and following the above-mentioned guidelines, healthcare providers can easily tackle and come out from stress. Also, they can avoid payment recoupment and unfavorable consequences. 

Prior to a CMS audit, it's always a smart option to be proactive and carry out routine internal reviews and compliance audits to find and fix any mistakes or non-compliance concerns.

In conclusion, the government uses a CMS audit process to make sure that healthcare suppliers and providers are adhering to Medicare and Medicaid requirements. A CMS representative will examine a provider's billing and medical records during an audit to make sure they are correct and compliant with legal requirements. Providers should be ready to respond to any inquiries and offer any required paperwork.

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