Illustrative examples
How we respond in common audit situations.
Every example on this page is a composite built from common payer-audit patterns. None describes a specific client or claims a past result. Each one shows how we respond and why.
Example scenario · Post-payment audit · IOP, average daily census of 48
The letter. A commercial payer audits 30 charts from an 18-month period, cites medical-necessity failures, missing treatment-plan updates, group-therapy documentation gaps, and late concurrent reviews, and extrapolates the findings into a seven-figure recoupment demand. The program has 60 days to respond.
What is at risk. The demand covers 18 months of revenue, recalculated with a statistical method the program cannot see. The payer's findings will also shape how it reviews the program's later claims.
How we handle it. Re-review every sampled chart. Test the extrapolation method: how the sample was drawn, how the error rate was calculated, and whether the sample supports applying that rate to every claim in the period. Rebuild the medical-necessity record using ASAM criteria and documented clinical progress. Negotiate directly with the payer's audit team.
Illustrative example. A composite of common payer-audit patterns, not a specific client engagement. It shows how our team responds. Real outcomes depend on documentation quality, how the payer approaches the review, timing, and the facts of the case.
More examples
Four other situations.
Example · Pre-payment review · PHP, average daily census of 32
Claims held, payroll at risk.
The program's largest payer, about 60% of revenue, puts every claim on pre-payment review for insufficient medical-necessity documentation and gives no end date.
How we handle it: identify exactly which documentation the payer is flagging, fix those charts first and resubmit them in weekly batches, talk directly with the payer's medical director, and change the documentation process so claims keep getting released.
Example · Documentation rebuttal · SUD residential, 60 beds
Most findings turn out to be technical.
A Medicaid managed care plan audits 25 charts and extrapolates across 1,200 claims over 24 months. Most "deficiencies" are technical: e-signatures that exist but did not print on exported PDFs, and ASAM documented in narrative while reviewers score a grid.
How we handle it: rebut each finding, use EHR metadata to prove the signatures exist, and map the ASAM documentation to the payer's scoring grid.
Example · Several payers at once · SUD residential and MAT
Three payer audits in 60 days.
A pre-payment review from one payer, a post-payment audit from a second, and a desk audit from a third, all at once, against one internal team.
How we handle it: act as the single point of contact with all three payers, fix problems the audits share once and apply the fix to all three, and deal first with the issues holding up the most revenue.
Example · Prevention · PHP and IOP, average daily census of 80
Before any letter arrives.
Leadership sees the warning signs: inconsistent utilization review timing, no standard templates, no internal audit process. No payer notice exists yet.
How we handle it: review a sample of charts internally to identify where the risk is coming from, then spend 6 to 8 weeks fixing it: documentation standards, EHR prompts, a deadline calendar, staff training, and regular internal audits.
Where would a payer's reviewer start with your charts?
Tell us what the letter says, with no patient information, or start with the Exposure Assessment.