US · guidance
CMS Pub. 100-08, ch. 1, § 1.3.9
Provider Self Audits
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.
History
(Rev. 11032; Issued: 09-30-21; Effective: 10-12-21; Implementation: 11-10-21)
Provenance
- Source
- cms.gov
- Retrieved
- 2026-08-25
- Edition
- iom-2026-08-25
- Content hash
b49c01c2d30033d5ac62e0755a16c5f7bb56503e13f4757417e14d15f6613725
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