Facing a Medicare audit can be worrisome for medical practices, which is why having a strong New York Medicare audit defense is vital to protecting your practice. Explore what it takes to respond to government queries appropriately, how to prepare for an audit, and why it’s so important to hire a healthcare lawyer to advocate for you throughout the process.
Medicare Audits in New York
Medicare audits happen as a way to verify that a healthcare provider has complied with federal billing and documentation requirements. Auditors look at claims submitted for reimbursement and compare these to medical records, supporting documentation, and coding. An audit can involve a sample of claims or a broad review of the full billing history. If errors are found, the auditor may seek repayment of any alleged overpayments or impose other corrective measures.
In 2025, the Centers for Medicare & Medicaid Services (CMS) reported an improper payment rate of 6.55%, which translates to $28.83 billion. CMS also plans to increase auditing rates from 35 records per health plan to between 35 and 200.
Why Audits Happen?
Medicare audits aren’t always triggered because the practice did something wrong. Often, they’re initiated through automated data analysis, which can flag anomalies. Some of the common triggers include: billing patterns that are different from those of other providers, missing or incomplete documentation, and random compliance reviews. Even patient complaints can be reason enough for an audit to occur.
CMS and other contractors rely on data analytics to identify outliers in billing behavior.
The Risks of a Medicare Audit
A Medicare audit can significantly impact a healthcare practice. If errors are found, the practice may face repayment demands that can be very costly. There could also be a suspension of Medicare payments and exclusion from other federal healthcare programs. In serious cases, the practice may be referred to a law enforcement agency for investigation. Even professional licensing could be at risk.
Providers increasingly rely on experienced counsel familiar with Medicare audit laws and compliance standards. This can help them manage risks effectively and navigate audits with confidence.
The Medicare Audit Process
Medicare audits follow the same basic structure. This looks like:
- Initial Notice or Record Request: The provider receives a request for medical records or documentation supporting billed services.
- Submission of Documentation: Providers are required to submit accurate and complete records before the deadline given to them.
- Review and Analysis: Auditors examine documentation for medical necessity, coding accuracy, and compliance with Medicare’s guidelines.
- Preliminary Findings: The auditor provides the results of their findings to the contractor.
- Final Determination: The provider receives a final audit report that may require repayment or further appeal.
Medicare audit laws govern documentation requirements for medical necessity, coding accuracy, and billing compliance, and the timeframes for responding to audit requests. They let practices know about their appeal rights and how the process unfolds. These federal rules intersect with state-level healthcare regulations, which makes compliance considerably more complex for providers.
A New York Medicare audit defense attorney can help at every step of the process by offering guidance and keeping you informed of your rights.
Why Hire a Healthcare Lawyer From Weiss Zarett Brofman Sonnenklar & Levy, P.C.?
Many healthcare providers unintentionally hurt their audit outcomes by making mistakes that could have been avoided. These errors can increase repayment amounts and even trigger expanded legal investigations. A strong defense isn’t just about responding to audit requests. It involves managing risks, preparing documentation properly, and challenging improper findings in New York.
Weiss Zarett Brofman Sonnenklar & Levy, P.C., can partner with you to work through these audits by:
- Conducting internal compliance reviews
- Preparing narrative justifications for medical necessity
- Analyzing patterns in billing
- Filing administrative appeals
- Challenging overpayment calculations
- Negotiation, repayment reductions, or settlements
The stakes can be high when it comes to audits within healthcare practices. Having the right attorney on your side matters.
FAQs
How Can You Prepare for a Medicare Audit?
To prepare for a Medicare audit, begin by organizing all records connected to the claims that are under review. Gather patient files, billing records, physician notes, and coding information. The auditors may also ask for other specific documents. Make sure your staff understands audit procedures and be clear about expectations and protocol.
An experienced New York Medicare audit defense attorney can help evaluate concerns, inform you of your legal rights, and develop a strategy for responding to the government auditors.
What Should You Not Say During an Audit?
Some of the things not to say during an audit include speculating, guessing, or stating claims that aren’t supported by documentation. If a provider doesn’t know the answer to a question, verify the information before responding. Casual comments can be misinterpreted and cited in the audit. Don’t alter records, and remain professional in communication with the auditors.
Does a Medicare Audit Mean You Were Accused of Wrongdoing?
An audit doesn’t necessarily mean there has been wrongdoing, but understanding why an audit was triggered can help you better prepare. A Medicare audit can be triggered by data analytics, unusual patterns in billing, and coding inconsistencies. High utilization rates, referrals from other agencies, and random compliance reviews can also initiate an audit. Federal contractors routinely analyze claims data to identify trends that differ from peer providers.
How Far Back Can NY State Audit You?
How far back NY State can audit you really depends on the specific auditing authority, the programs being audited, and other applicable regulations. Medicare reviews can often involve claims that were submitted several years earlier, which requires auditors to check records from that period. State and federal agencies often function under different regulations and have different record retention requirements.
Contact Weiss Zarett Brofman Sonnenklar & Levy, P.C., Today
Serving clients in Nassau County, Suffolk County, and the surrounding areas, Weiss Zarett Brofman Sonnenklar & Levy, P.C., can offer experienced guidance for healthcare providers facing an audit or planning for the possibility of one. Our firm can help you protect your practice, reduce financial exposure, and comply with evolving regulatory standards in New York State.
Contact us today to schedule a consultation or visit our office at 333 New Hyde Park Road, close to the intersection of Interstate 495 and the Long Island Expressway.
