Separate a Documentation Review From a Fraud Allegation

A Medicare review, repayment request, audit, subpoena, or criminal charge are different events. A request for records does not by itself establish fraud. Start with the actual notice: identify the sender, claim or patient identifiers, date range, deadline, submission method, and whether the request is administrative, civil, or criminal.

CMS explains that an Additional Documentation Request may be used to obtain records supporting a claim and that response timing depends on the type of review and contractor. Its ADR guidance is a useful starting point for understanding that process.

Preserve Clinical, Billing, and Communication Records

The relevant file may include medical records, orders, coding support, claim data, remittance advice, prior-authorization materials, enrollment records, schedules, internal policies, and communications with payers or contractors. Preserve the original EHR data and audit logs where available. Do not alter, delete, backdate, or recreate records after receiving a notice.

A production log should show what was collected, from where, for which patient or claim period, and when it was submitted. That makes it easier to determine whether a later question concerns a missing item, a coding issue, medical necessity, enrollment, or a separate allegation.

Review the Scope Before Responding

Read the request carefully. Some requests concern a defined set of claims, while others seek policies, billing data, or records for a broader period. Match the response to the request instead of sending a general collection of unrelated patient information. Privacy, privilege, and patient-record requirements may affect how materials should be reviewed and produced.

If a discrepancy appears, preserve the underlying record and identify the factual source of the difference. An incomplete form, coding question, or disputed medical-necessity determination should be evaluated in context rather than labeled as intentional misconduct without evidence.

Know Where Program-Integrity Guidance Comes From

CMS maintains the Medicare Program Integrity Manual, which includes material on reviews, contractors, and program-integrity processes. The Office of Inspector General also publishes information about health care fraud. Those resources provide general background; the notice, governing program rules, and facts control the individual matter.

Questions for an Internal Review

Before responding, identify the claims involved, the relevant coverage or billing rule, and the source records that support each claim. Confirm whether the practice has records for the entire requested period and whether any material is held by a hospital, laboratory, billing contractor, or former employee. Keep those collection questions separate from an explanation of the facts. A complete record of what was available, when it was obtained, and what was produced can be important if the scope changes later.

Routine compliance work may continue, but historic records should remain intact. The purpose of the review is to provide an accurate, traceable response that matches the request.

Keep Staff Discussions Focused

Employees may have useful information about how claims, records, or schedules were created. Preserve their names and roles, but avoid asking anyone to revise notes or coordinate an account of the facts. Questions should focus on locating source records and understanding ordinary workflows. If a practice holds a meeting about the request, keep a factual record of the purpose, participants, and documents identified. That protects the integrity of the underlying information while the matter is reviewed.