5 Tips for How to Prevent CMS Audits for Medical Practices

October 12, 2021 by Antonio Arias, MBA, CHBME

Topics: Practice Management, Medical Billing Company

Part of treating Medicare patients is that your medical practice may be subjected to Medicare audits. These can lead to suspension of payments and Medicare fees if your medical practice isn’t up to snuff with current regulations and laws. 

Unfortunately, healthcare waste, fraud, and abuse lead CMS (Centers for Medicare and Medicaid Services) to be diligent in recovering as much federal money as possible. Even when there’s no intent to be dishonest, a medical practice can still face penalties if found guilty of improper Medicare billing. While there is no way to avoid facing a Medicare audit, there are ways to prepare for one to reduce any negative outcomes.

How Audits Impact Your Medical Practice


By identifying errors and devising remedial actions to eliminate them, audits serve a vital role in a healthcare organization’s compliance plan.

Medical audits provide a mechanism to:

  • Review quality of care provided to patients
  • Educate providers on documentation guidelines
  • Determine if organizational policies are current and effective
  • Optimize revenue cycle management
  • Ensure appropriate revenue is captured
  • Defend against federal and payer audits, malpractice litigation, and health plan denials

What Are CMS Audits?

Audits of any business essentially aim to see how compliant that organization is with whatever set of rules and regulations. That’s essentially the same goal with audits conducted by CMS of medical practices. 

These program audits measure compliance in terms of its contract with CMS, in particular, the requirements associated with access to medical services, drugs, and other enrollee protections required by Medicare. Since CMS is a department of the federal government, extra efforts are in place to prevent and reduce waste, abuse, and fraud regarding CMS funds and information.

The program areas for the 2021 audits include:

  • CDAG: Part D Coverage Determinations, Appeals, and Grievances
  • CPE: Compliance Program Effectiveness
  • FA: Part D Formulary and Benefit Administration
  • MMP- SARAG: Medicare-Medicaid Plan Service Authorization Requests, Appeals, and
  • Grievances
  • MMP- CCQIPE: Medicare-Medicaid Plan Care Coordination Quality Improvement Program
  • Effectiveness
  • ODAG: Part C Organization Determinations, Appeals, and Grievances
  • SNP-MOC: Special Needs Plans – Model of Care

What Is the CMS Program Audit Process?

There are four phases to a CMS audit:

  1. Audit Engagement and Universe Submission: This entails the six-week period prior to the fieldwork portion of the audit. During this phase, a sponsoring organization is notified that it has been selected for a program audit and is required to submit the requested data, which is outlined in the respective Program Audit Data Request document.
  2. Audit Field Work: Program audit fieldwork is conducted over a period of three weeks. Generally, audit fieldwork is conducted via webinar with the exception of the CPE review, which may occur onsite during the last week of audit fieldwork. 
  3. Audit Reporting: Audit reporting occurs in multiple stages beginning at the conclusion of audit fieldwork. As previously mentioned, CMS first shares audit results with the medical practice at the exit conference via the preliminary draft report. However, the findings in this preliminary draft report are subject to additional review and evaluation after all supporting documentation has been received and evaluated, at which point classification occurs. 
  4. Audit Validation and Close-Out: This final phase of the program audit process is the longest phase as it occurs over a period of approximately six months. In this phase, a sponsoring organization has an opportunity to demonstrate to CMS that it has corrected the noncompliance that was identified during the program audit.

What Does CMS Look For in Audits?

By conducting audits, either at random or as suspicious activity is reported, CMS works to prevent, reduce, or address a medical practice exploiting CMS money or information, regardless of intention. 

Again, it all comes back to compliance with CMS regulations and laws, which have the potential to change each year. Such issues to address might include falsifying claims that are billed to Medicare, charging excessively for Medicare services or supplies, making false statements on applications to participate in federal programs, and more.

How Much Will CMS Increase Audits in the Future?

CMS’s budget for fraud, waste, and abuse mitigation has doubled from 2021 to 2022. CMS specifically proposed to “conduct greater levels of medical review in FY 2022” and sought a $50.5 million increase in funding for these activities. 

Medical review activities include pre- and post-payment audits and also encompass the Targeted Probe-and-Educate (TPE) process. CMS also requested additional funding for modeling and analytic tools aimed at identifying fraud, waste, and abuse.

The funding increase also allowed CMS to hire more administrative law judges (ALJs) in an attempt to reduce the backlog at the third level of Medicare provider appeals, which currently sits at five years

5 Tips to Avoid CMS Audits

Prevent Billing and Coding Mistakes


As a physician, payers trust you to provide medically necessary, cost-effective, quality care. You exert significant influence over what services your patients get. You control the documentation describing services they receive, and your documentation serves as the basis for claims you submit. Generally, Medicare pays claims based solely on your representations in the claims documents.

Coding facilitates the billing process by bringing uniformity to the procedures through recognizable codes. Using standard diagnosis codes and procedure codes, the medical coder ensures that Medicare will recognize the billed item and how the diagnosis warrants that procedure, test, or treatment. When the coding on the claim does not meet the Medicare requirements and Medicare pays the claim anyway, the audit may discover this mistake. To prevent coding mistakes, make sure the most current coding books are on hand and use appropriate modifiers according to Medicare guidelines.

Provide Accurate Documentation

When in doubt, document. Because there are multiple systems that could be involved in an audit, medical organizations need to make sure that everything is documented. This includes data presented on meaningful use reports generated by EHR and all other evidence.

This is important for researching during or after an audit and for justifying moves that have been made after the fact. Companies that have the proper documentation of every decision made and each process change will be able to easily find any potential trouble areas and address processes that are pointed out after an audit.

Auditors will be looking for discrepancies between all information that is supported and what should have actually been done. By knowing the right practices and eliminating errors with better technology, discrepancies can be kept to a minimum.

Perform a Self-Audit

Perform your own random mock audits based on the same criteria as a Medicare auditor to uncover what they would find, before they show up at your door. 

While there isn’t an exact method of determining what an auditor would find, there are a few things that can be done to create a checklist of sorts. Visit the CMS website for the most up-to-date information on submitting claims that comply with Medicare guidelines.

Review Every Process

Reviewing every process pertinent to the medical billing and patient information systems side of your medical practice is important in preventing CMS audits. As medical billing and patient information systems become more integrated, the need to review every process becomes more critical since a simple change could require an organization to upgrade multiple other systems to be successful.

This also happens when regulations change; if the coding of a specific medical procedure changes, every system that uses those codes needs to be examined to make sure that it can handle that change.

Train Your Staff

One of the most common reasons a healthcare organization fails an audit is human error. 

This is where a well-trained and experienced billing team can be considered the most important driver of revenue for medical practices. Billers and coders who are credentialed and certified from the proper associations are less likely to make mistakes and understand how to properly manage these solutions.

A qualified and confident staff is also more likely to be aware of industry changes that impact operations and can implement changes to remain up-to-date. This kind of staff is also more likely to advance principles that can make a bigger difference in the revenue cycle.

Avoid CMS Audits with NCG Medical!

One way to lessen the odds of triggering a billing and coding audit and improving your revenue cycle management is to contract with a medical billing company. An experienced and proactive firm with the right resources, detailed practice management knowledge, capacity, and medical billing audit tools can manage all of your claims and help you spot audit-inducing issues before they happen.

With four decades of experience helping healthcare practices improve their billing and coding efficiencies, NCG Medical can help protect your practice from the potentially devastating effects of a medical billing audit. Our team of certified medical coders, MBA, and CPAs can also help you streamline your practice management to improve efficiencies, trim costs, and boost revenue. To learn more about the medical billing audit services we offer, as well as the customized solutions we can create to meet your healthcare practice’s specific needs, contact our team today.

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