Medicare Audits

Medicare audits arrive by letter, and they escalate fast. What begins as an Additional Documentation Request from a Medicare Administrative Contractor can produce an overpayment demand running to six or seven figures, a recoupment order that starts pulling money from future claims, and, in a growing number of cases, a referral to the Office of Inspector General or the Department of Justice under the False Claims Act. Black Law P.A. represents Florida healthcare providers at every step of that process, from the initial documentation response through federal district court review.

The audits themselves come from several different contractors, each with its own scope and consequence: Recovery Audit Contractors (RACs), Unified Program Integrity Contractors (UPICs) and their predecessor ZPICs, Comprehensive Error Rate Testing (CERT) reviewers, Supplemental Medical Review Contractors (SMRCs), and the Targeted Probe and Educate (TPE) program run by the MACs. The procedural rules, timelines, and appeal rights vary meaningfully across programs. So do the strategic choices about how to respond.

Our engagements include:

• Preparing responses to Additional Documentation Requests (ADRs) and other initial audit inquiries
• Defending overpayment demands and preserving the right to recoupment relief
• Challenging statistical sampling and extrapolation methodology, including expert-driven challenges to sample size, universe definition, and stratification
• Level 1 Redetermination requests to Medicare Administrative Contractors
• Level 2 Reconsideration by Qualified Independent Contractors
• Level 3 Administrative Law Judge (ALJ) hearings at the Office of Medicare Hearings and Appeals
• Level 4 Medicare Appeals Council review at the Departmental Appeals Board
• Level 5 Federal District Court review under 42 U.S.C. § 405(g)
• Corporate Integrity Agreement (CIA) negotiation and compliance
• OIG investigation response
• Voluntary self-disclosure strategy under the OIG Self-Disclosure Protocol and CMS Voluntary Refund Process
• False Claims Act and qui tam defense in Medicare-billing matters, including 31 U.S.C. § 3729 and related state analogs

We work with physicians and physician groups, behavioral health providers, skilled nursing and assisted living facilities, home health agencies, hospice providers, durable medical equipment suppliers, ambulance services, clinical laboratories, and hospitals of every size. In many matters we coordinate with clients' existing billing consultants and clinical documentation improvement teams to build the strongest evidentiary record before deadlines run.

Two operational realities shape almost every audit engagement. First, deadlines are unforgiving. A missed 120-day Level 1 window forfeits meaningful appeal rights. A missed 30-day recoupment-hold window means Medicare begins withholding future payments while the appeal proceeds. Second, the record made at the front end determines the outcome at every subsequent level. By the time a matter reaches an ALJ, the reviewing judge is looking largely at what the provider produced during redetermination. Getting the initial response right matters more than any single later step.