Provider Self Audits

1.3.9 – Provider Self Audits (Rev. 11032; Issued: 09-30-21; Effective: 10-12-21; Implementation: 11-10-21) Providers may conduct self-audits to identify coverage and coding errors. The Office of Inspector General (OIG) Compliance Program Guidelines can be found at https://oig.hhs.gov/compliance/compliance-guidance/index.asp and the statistical guidelines in https://oig.hhs.gov/authorities/docs/selfdisclosure.pdf (if statistical sampling is utilized during the audit). The MACs shall follow chapter 4, section 4.2.2.8.1.3, handling any voluntary refunds that may result from these provider self- audits. Most errors do not represent fraud. Most errors are not acts that were committed knowingly, willfully, and intentionally. However, in situations where a provider has repeatedly submitted claims in error, the MACs shall follow the procedures listed in chapter 3, section 3.2.1. For example, some errors will be the result of provider misunderstanding or failure to pay adequate attention to Medicare policy. Other errors will represent calculated plans to knowingly acquire unwarranted payment. Per chapter 4, section 4.2.1, MACs shall take action commensurate with errors made. The MACs shall evaluate the circumstances surrounding the errors and proceed with the appropriate plan of correction.