Identify the Source and Scope of the Audit

Medicare reviews may be conducted by different contractors and can use different notices, claim lists, deadlines, and submission channels. Before gathering records, preserve the notice and identify the requesting organization, claims or beneficiaries named, period under review, deadline, and stated purpose. An audit request should be read as written rather than treated as a general request for every practice record.

Build a Controlled Response File

Create a file containing the request, a copy of each record gathered, the source system, the person who collected it, and the date of production. The response may require medical records, orders, coding support, billing data, or other specified documents. CMS notes that an Additional Documentation Request may seek records needed to support a claim and that a late response can affect the determination.

Preserve Original Records

Do not alter, backdate, delete, or recreate clinical or billing records after notice of a review. Preserve the EHR version, audit trail, billing-system data, relevant emails, and communications with contractors. If a record is corrected through an ordinary, documented process, retain the original version and the reason for the correction.

Where the records are held by a billing company, hospital, laboratory, or other third party, request copies through the normal channel and log the request. A response should identify what was provided and any material that could not be located.

An Audit Does Not Resolve Every Legal Issue

A documentation review may lead to a claim determination, repayment issue, education, further inquiry, or no action. A criminal charge involves a separate legal process. The United States Courts overview of criminal cases describes the general federal framework after charges are filed. The actual notice, governing rule, and evidence determine the appropriate response.

Keep communications factual and limited to the scope of the request. If the practice receives a subpoena, target letter, or other formal investigative document, preserve it and obtain advice about the response before making explanatory statements.

Check the Production Before It Is Sent

Before a submission is made, compare the selected records with the claim list and request. Confirm that each document belongs to the correct patient, date of service, provider, and billing period. Verify that scanned pages are complete and legible, and retain a copy of the production and delivery confirmation. If a requested item cannot be located, document the search steps instead of substituting a recreated record.

This review is also an opportunity to separate an administrative request from information that may require additional legal or privacy analysis.

Track the Deadline and Delivery Method

Use the response method stated in the notice and retain proof of delivery. CMS notes that records may be submitted through several channels depending on the review. If the practice needs clarification about a claim number, record type, or delivery instruction, preserve the written question and answer. A dated log of communications can prevent confusion about whether a request was answered, extended, or narrowed.

Retain the final copy of every submission with the delivery confirmation.