Is There a Fox in the Hen House? Audit Risks in Wound Care Programs

Hospitals and physician practices—especially those operating wound care clinics—are facing heightened scrutiny from CMS, third-party payors, and external audit contractors. These entities often arrive unannounced, combing through claims, documentation, and coding practices for inconsistencies.

If your team isn’t prepared, the audit process can feel like a fox slipping quietly into your wound center—taking with it time, revenue, and peace of mind.

To protect your program, it's critical to understand the most common audit types and documentation requests your facility may encounter—so you can respond confidently and reduce risk.

Federal Government Audits (e.g., CMS)

These audits are conducted to ensure compliance with federal healthcare programs such as Medicare and Medicaid. They typically focus on claims, billing practices, and adherence to applicable regulations.

Recovery Audit Contractor (RAC) Audits

RACs are carried out by third-party contractors tasked with identifying and correcting improper Medicare and Medicaid payments. This includes both overpayments and underpayments.

Comprehensive Error Rate Testing (CERT) Audits

CERT audits measure the rate of improper fee-for-service payments in Medicare. Conducted by CMS contractors, these audits identify claims that fail to meet Medicare requirements and may indicate potential fraud.

Medicare Administrative Contractor (MAC) Audits

MACs are regionally assigned entities responsible for processing Medicare claims. They also perform audits to verify accurate billing, correct coding, and documentation compliance.

SMRC and UPIC Audits

Supplemental Medical Review Contractor (SMRC) and Unified Program Integrity Contractor (UPIC) audits are designed to assess program integrity. They focus on detecting improper payments and mitigating fraud, waste, and abuse.

Office of Inspector General (OIG) Audits

The OIG—part of the U.S. Department of Health and Human Services—investigates healthcare fraud and abuse. OIG audits often examine specific risk areas, including billing accuracy, quality of care, and patient data security.

Additional Documentation Request (ADR)

An ADR is a formal letter issued by a MAC or RAC to request supporting documentation for a submitted Medicare claim. The goal is to verify that the claim complies with Medicare policies and requirements. Providers must respond within strict timeframes to avoid claim denials or recoupments.

Targeted Probe and Educate (TPE) Audits

TPE audits are conducted in rounds and typically include a review of 20–40 claims per provider, per service or item. Providers can undergo up to three rounds of review, with one-on-one education provided after each round based on findings.

Keep the Fox Out of the Hen House

Are you confident your team is taking the necessary steps to prevent costly audits and protect the revenue they’ve worked hard to earn?

At Shared Health Services, we work closely with hospitals and physician practices to provide targeted education and side-by-side virtual support for wound care and revenue cycle teams. Our focus is on improving clinical outcomes, aligning documentation with LCD and LCA requirements, and staying ahead of shifting regulations.

Reduce your audit risk by partnering with Shared Health Services.

We help keep your eggs — and your revenue — right where they belong.

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