Reducing provider abrasion during a recovery audit


Posted October 1st, 2015


Individuals listening in a meeting


By Lane Edenburn and Brian Fisher

As a Medicaid agency, you’re tasked with maintaining a provider network of sufficient size, quality, geographic range and breadth of services to meet the needs of your state’s most vulnerable population. But maintaining positive, productive provider relations during a recovery audit can be challenging. Here are some tips to keep in mind to minimize provider abrasion during what can be a stressful event for providers.

Pull claims with the highest likelihood of error

It goes without saying that providers don’t like to pull claims, and if the majority of those they pull prove error free, relations are sure to sour. If just 10 percent of the claims they pull have an actual error, take a look at your analytics. They could be at fault. Check with your RAC vendor to make sure your analytics flag claims with the highest likelihood of impropriety to avoid wasting your providers’ time and effort.

Stick to a reasonable sample size

Don’t ask your providers to pull the maximum number of claims allowed just because you can. It’s financially burdensome for both you and the provider. Stick to 50 claims or fewer. Most providers can turn that number around reasonably quickly, and if they have anything to correct, they can correct it sooner rather than later. Using a minimal figure leaves the door open for you to increase your sample size at some point in the future, if necessary.

Pull the most recent claims

If you suspect your provider made an error rather than perpetrated fraud, don’t research claims paid three to four years ago for additional evidence. Choose the most recent ones. For one thing, the policy may have changed since the time the claim was paid, and it may have been properly submitted for the time. Second, the provider may have updated the office claims submission policy since then, and more recent claims are correctly coded. Educating the provider on proper coding when he or she has already rectified the situation could damage relations.

Prevent duplicate audits

Avoid repeat audits of the same claim, by different departments, by establishing a process to match claim identifiers (TPNs) before the audit begins, and removing any claims on your list that have already been reviewed. Make sure each department adheres to the process. Duplicate reviews unnecessarily inconvenience your providers and could fuel resentment.

Be consistent

A quality assurance plan incorporating multiple layers of review can help you verify whether an audit is needed. The plan should include an audit of your reviewers’ work to make sure claims with the same error get the same determination. If your reviewers have different perspectives, resulting in some claims passing and similar claims failing, your credibility could suffer.

Be organized

As your mother always said, “Be careful.” Keep your records up to date so your correspondence goes to the correct address, and don’t lose the documentation your providers send you. Asking providers to resend documentation can damage relations.


It may be unrealistic to expect the recipient of an audit letter to be receptive. Your best approach may be to make it clear that you are open to discussion. Hand them your card. Give them every opportunity to call or meet with you one-on-one, to state their case or provide additional documentation. Give them plenty of opportunity to explain their position. Educate them, and let them know you aren’t looking at every one of their claims. Always inform your providers of their right to appeal.

Craft good letters

Train your staff to craft letters with sufficient detail to explain what rule or policy was violated so that providers can check on the matter themselves. For coding errors, for instance, reference the code that’s at issue, give a detailed narrative describing the problem and attach the claims you’ve identified as out of compliance. Be sure to point out each claim's specific violations.


Understandably, providers will be more receptive to your educational efforts if they take place before payment rather than after, during a contentious recovery effort. Whether you provide education before or after payment, your initial letter detailing reasons for the audit may be sufficient to educate the provider and achieve compliance. A phone call or one-on-one may also suffice.

However, if you find a particular error is widespread among your network, consider a proactive approach to getting the word out. If the issue pertains to a particular sector, work with the state association representing that industry, clinical specialty or employee job type to spread the word. Options include writing an article for a bulletin or website and conducting seminars independently or in conjunction with an association event.

Be flexible

Be firm but flexible. Don’t drop the hammer right away. Your provider may be undergoing several audits at the same time — especially if it’s hospital based — and may legitimately need more time to submit documentation. Have steps in place for an extension. The more flexible you can be, the more appreciative they’ll be.

Be fair

Just having someone objectively listen and consider what a provider is contending can significantly improve provider relations. To help strengthen your credibility, push your RAC vendor to identify underpayments as well as overpayments. If your providers feel you are fair and you’re making the effort to pursue underpayments, as well, you can gain their trust and goodwill.

Following these tips may not guarantee positive, productive relations during a recovery audit. However, by fostering an atmosphere of respect and thoughtful deliberation, you’ll likely go far in maintaining and improving relationships and avoiding abrasion.

To learn more about best practices in program integrity, read our handbook, “Identify, Predict, Prevent, Recover: A Handbook for Medicaid Program Integrity.”

About the authors

Lane Edenburn is vice president, government program integrity solutions, at Optum, and Brian Fisher is integrity account manager, Iowa Medicaid program, at Optum.


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