Expert Insights on Mastering Medicare Audits

In this episode of Compliance Conversations, host CJ Wolf sits down with Alicia Shickle, AHFI, CHC, CPC, CPCO, CPMA, CRC, the President and CEO of ProCode Compliance Solutions LLC, a healthcare compliance veteran with nearly four decades of experience. Alicia has seen it all, from family practice administration to consulting with providers across the country on compliance and revenue cycle integrity.  

Key Takeaways from the Episode:

1. Understanding the Types of Medicare Audits

Alicia breaks down the different types of Medicare audits you might encounter, such as Targeted Probe and Educate (TPE) audits and Unified Program Integrity Contractor (UPIC) reviews. Each type of audit has its own focus and consequences, and understanding the differences is crucial to managing them effectively. Whether it’s a routine check or an investigation into potential fraud, Alicia’s insights will help you know what to expect and how to prepare. 

2. The Top Issues Triggering Audits

From improper coding to inadequate documentation, Alicia highlights the top issues that can land providers in hot water. She emphasizes the importance of staying on top of medical necessity guidelines, proper use of modifiers, and ensuring thorough and accurate documentation. These are the areas where auditors often find errors, and being proactive can save your practice from costly mistakes. 

3. Navigating the Medicare Appeal Process

One of the most valuable parts of the episode is Alicia’s deep dive into the Medicare appeal process. She walks listeners through the five levels of appeal, from redetermination to judicial review, offering practical advice on how to approach each stage. Alicia stresses the importance of responding promptly, gathering all necessary documentation, and getting expert help early in the process to maximize your chances of a successful appeal. 

4. Proactive Compliance Programs: Your Best Defense

Alicia also discusses the critical role of proactive compliance programs in preventing audits and mitigating risks. Having a robust compliance program in place—complete with policies, training, and regular auditing—can make all the difference. As Alicia puts it, “Be audit-proof.” By taking these steps, you can catch issues before they become problems and demonstrate to auditors that your practice is committed to compliance. 

Why You Should Listen

This episode is packed with actionable insights and practical tips that can help any healthcare provider better understand and manage Medicare audits. Whether you’re new to the process or have been through it before, Alicia’s advice is invaluable. 

In a world where the only constant is change, staying informed and prepared is key.  

About Alicia Shickle

Alicia has decades of clinical and administrative healthcare experience. Her areas of expertise include revenue cycle integrity, documentation, coding and billing compliance, Medicare, MSP, and Medicaid regulations, practice workflow and operations, compliance program assessments, development, and implementation.  

Alicia provides advisory services to attorneys, healthcare administrators, providers, and organizations. She frequently works with business litigation and health law practices on fraud and abuse intervention and providing independent and objective assessments for both plaintiff’s and defense teams.  

She works closely with clients on both routine and complex documentation and coding reviews. She provides in-depth coding and claims data analysis, education, and assists providers with navigating complex regulatory and policy requirements, identifying and mitigating potential FCA risks while optimizing revenue. She has extensive experience developing and implementing effective compliance programs including all seven elements.  

Alicia served as the Director of Compliance for the American Academy of Professional Coders (AAPC). She has worked with some of the top consulting and health law practices and, was a Family Practice Administrator for over a decade.  

Alicia has presented educational training boot camps and seminars nationally on compliance, documentation and coding, and practice management. She was a medical billing and coding instructor at a community college. She is a frequent author for online physician blogs, and journals. Alicia is an Accredited Health Care Fraud Investigator (AHFI) with the National Health Care Anti-Fraud Association (NHCAA), and is certified in Healthcare Compliance (CHC, CPCO) through the Health Care Compliance Association (HCCA), and AAPC. She is a Certified Professional Coder (CPC), Certified Professional Medical Auditor (CPMA), and certified in Risk Adjustment Coding (CRC). She is also a Certified Physician Practice Manager (CPPM).  

Alicia is an active member of the American Academy of Professional Coders (AAPC) and served as the President of AAPC’s Manhattan Local Chapter for two years. She is a member of the Health Care Compliance Association (HCCA), and the National Health Care Anti-Fraud Association (NHCAA), and American Health Lawyers Association (AHLA). She is a member of American Health Information Management Association (AHIMA), the National Alliance of Medical Auditing Specialists (NAMAS), and a member of Medical Group Management Association (MGMA).