How to survive a medicare audit.(Guest Editorial)

Mention of a government audit usually raises the specter of the Internal Revenue Service. But physicians who treat Medicare beneficiaries need to know about a far more likely audit source: the Centers for Medicare and Medicaid Services and its nationwide network of Medicare carriers.

The 34 private insurance companies that administer Medicare are required by the terms of their contracts with the government to audit a certain number of physicians each year, whether they suspect improprieties or not.

While 5% of Medicare providers are audited each year, your risk is not necessarily 1 in 20. It could be higher if you are an "outlier"--a physician who is more than two standard deviations away from the "norms" for your specialty and practice area, who consistently bills the higher-level E & M [evaluation and management] codes, or who bills lots of obscure and seldom-used codes.

Your chances also increase if Medicare receives complaints about you from patients, other physicians, or even your employees. Beneficiaries and office employees are encouraged, with significant potential monetary rewards, to report anything they think might be considered fraud or abuse.

Which means, of course, that your best defense against audits is good charting, precise coding, and scrupulous avoidance of all things abusive or fraudulent.

So what should you do if you receive the dreaded letter requesting copies of 15-40 of your charts?

First, keep in mind that a Medicare audit is similar to one by the IRS: You are guilty until proven innocent. The burden of proof is on your shoulders.