By Michael Rosenblat on March 18, 2021

Government Audits of Medicare and Medicaid Providers on the Increase

Chicago – As the Federal Government through its various agencies, such as Health & Human Services (HHS), Centers for Medicare & Medicaid Services (CMS), and the States primarily through their Medicaid Fraud Control Units (MFCU) and the Office of the Attorneys General, investigations of billing irregularities and fraud are on the increase. These investigations of healthcare providers consume substantial resources and often come with a payment suspension of the provider’s Medicaid billings. 

Illinois Medicaid

The Illinois Medicaid program covers over 3 million individuals, with over 65% in managed care. The Office of Inspector General, Healthcare and Family Services, conducts audits, peer reviews, and advanced data mining. In 2016, the OIG recovered or saved $220.4 million through recoupments, cost savings, and cost avoidance. 

Medicare Audits

Various agencies can conduct Medicare audits from a United States Attorney’s Office to a paid contractor. Most USAO investigations will seek more than a recoupment for the alleged overpaid funds, as their investigations would likely be under the False Claims Act, which allows for treble damages plus a penalty for each false claim. If the investigation is criminal, the USA would likely seek a conviction under the health care fraud statute. (18 USC 1347)

Some of the third parties that conduct Medicare audits are:

Recovery Audit Contractors

RAC’s review post-payment claims to detect and correct improper payments to permit CMS, fiscal intermediaries (FI), and Medicare Administrative Contractors (MAC) to implement steps to prevent future erroneous payments. In Illinois, the RAC is Cotivit, LLC.

Medicare Administrative Contractors

A MAC processes Medicare Part A, Part B, or durable medical equipment (DME) claims for Medicare. MAC’s are the contact between Medicare and the providers, MAC’s process fee for service claims (FFS). Currently, there are 12 MAC’s and four DME MAC’s. 

Zone Program Integrity Contractors 

ZPIC’s are tasked to investigate fraud, waste, and abuse by health care providers. ZPIC’s conduct audits of health care providers on behalf of CMS. Unlike other contractors, RAC’s and MAC’s, ZPIC’s concentrate on fraud allegations, not billing errors. As such, ZPIC audits are more likely to result in a referral to federal law enforcement. 


Medicare audits can result in substantial recoupments, the suspension of payments, and even criminal prosecution. As a health care audit and defense law firm, we can develop an effective response to eliminate or mitigate audit, recoupment, or criminal prosecutions. Our firm is designed to defend health care providers, physicians, dentists, and home health agencies efficiently and effectively from allegations of overbilling to fraud. We have saved our clients hundreds of thousands of dollars in recoupments. 

Contact us today for a consultation.