What should a Provider or Department do if a letter is received from CMS, or any other government entity, requesting copies of medical records for a review or audit?

It is important to promptly and accurately act upon correspondence from governmental entities.  If a Provider or Department employee receives this type of correspondence, it should be presented promptly to the Department Manager for reporting and forwarding to the Compliance Office.

Examples of government entities include:

  • CMS (Centers for Medicare and Medicaid Services)
  • HealthDataInsights (the Medicare Recovery Audit Contractor or RAC)
  • Palmetto GBA (the Medicare Administrative Contractor or MAC)
  • Noridian (the UCSF MAC of Fall 2013)
  • Medi-Cal or HMS
  • CERT (Comprehensive Error Rate Testing Contractor)
  • Department of Justice
  • The Compliance Office will provide coordination and processing of the response as well as perform an internal review. Compliance will appeal any request for repayment, as supported by our internal review. The Compliance Office will also provide overall guidance for the response, including:

    • review of billing processes and documentation
    • drafting of cover letters and other appropriate correspondence
    • facilitation of timeline extensions, as needed
    • communication with the payor for any clarification needed