Medicare Auditors: What they're looking at, and why

Why This Topic Matters

Understanding the scope of Medicare audit activity helps organizations identify where their billing and documentation processes may be vulnerable. The article is useful for planning internal compliance efforts, strengthening monitoring, and preparing staff for external review by Medicare contractors and other investigators.

Article Sections

1. Overview of Medicare audit activity

   Introduces the broader audit environment and explains why external oversight remains a major issue for healthcare organizations.

2. Main areas monitored by HHS and government contractors

   Summarizes the broad categories of claims, billing, and program integrity issues that are routinely reviewed.

3. Types of audit activities conducted through HHS

   Describes several oversight and review programs used to examine billing patterns, cost reporting, medical review activity, payer coordination, and provider education.

4. Fraud investigation and enforcement

   Explains the roles of federal investigative and enforcement agencies in identifying and pursuing healthcare fraud.

5. Planning internal auditing and monitoring work

   Discusses the importance of maintaining an ongoing compliance and audit plan that addresses the areas most likely to be reviewed.