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Beyond adversity: A new approach to making Medicare and Medicaid audits beneficial

Maximize value by rethinking the audit process

By focusing on collaboration, communication and expertise, audits can evolve into a valuable tool for improving healthcare delivery. It's time to demystify the audit process and embrace it as a catalyst for positive change in the healthcare industry.

For many healthcare providers, Medicaid and Medicare audits evoke trepidation. Audits commonly lead to paperwork, raise questions about regulatory conflicts, and divert teams away from revenue-generating tasks. These burdens complicate the critical tasks of state agencies, healthcare providers and health systems striving to ensure quality care under tight budgets.

Although audits are plagued by communication gaps, unresolved overpayments and inadequate understanding of provider challenges, they shouldn’t be viewed as adversarial encounters. With the right foundation and processes in place, they can also be collaborative endeavors that benefit both Medicaid and Medicare plans and the providers.

In my years of experience, it’s clear that poor relationships and ineffective consultant-partners are driving a variety of misconceptions in our industry. And providers suffer as a result. 

Simplifying audits and turning them into mutually beneficial processes hinges on dispelling four pervasive industry myths:

Myth #1: Providers resist Medicaid audits

Reality: While there may be a perception that providers resist Medicaid audits, the truth is far more nuanced. The core issue lies in the imbalance between the perceived value of audits and their impact on providers. Our conversations and relationships with health systems and providers reveal that frustration stems not from the audits themselves, but from the mismatch between effort expended and benefits obtained.

Myth #2: Audits are conducted too frequently 

Reality: There's a common belief that audits, often conducted annually or every few years, are excessive and diminish in effectiveness over time. However, the frequency of audits isn't the primary concern; it's the effectiveness of the audit process itself. Communication gaps, unresolved overpayments, and inadequate understanding of provider challenges plague the system. It's not about the frequency but the quality of audits and their ability to address critical issues.

Myth #3: Consultants are detached entities 

Reality: Effective partners comprehend the day-in and day-out of providers. They go beyond a basic understanding of provider operations, know what questions to ask and how to communicate with different entities. Personal connections are to effective audits. Effective consultants put dedicated teams on the ground that work closely with providers year-round, build genuine relationships, and offer real-time communication to resolve issues. 

Myth #4: Audits focus solely on overpayments 

Reality: While overpayments are a significant concern, audits should extend beyond mere reviews of financial transactions. They should delve into pressing issues faced by providers, fostering genuine communication between providers and Medicaid. By addressing broader concerns such as reimbursement challenges and administrative hurdles, audits can become a tool for improvement rather than a source of frustration.

How to transform your Medicare/Medicaid processes

By prioritizing collaboration, communication and understanding in Medicare and Medicaid audits, organizations can transform regulatory obligations into invaluable tools for enhancing healthcare delivery. Embracing a collaborative approach involves fostering open dialogue and mutual respect between consultants, healthcare providers, and Medicare and Medicaid plans.

Effective healthcare payments and audit outcomes require integrated systems. Conduent Medicaid Suite (CMdS), for example, unites claims processing, financial services, pharmacy services, federal reporting, rebate programs, and more into one unified solution. 

Navigating compliance can be daunting, but with the right audit consultant, providers gain the needed relationships and tools essential for driving value, efficiency success, and healthcare delivery. 

Ready to discover how Conduent Government Healthcare Solutions can help your organization streamline Medicare and Medicaid payments, help reduce costs and identify overpayments? Visit us online to learn more at

About the Author

Jarett Crockett has been a payment analysis consultant for 13 years. He specializes in overpayments and identifying payment error trends with a focus on state Medicaid and managed Medicaid plans.

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