Preparing for Potential Audits

Medicaid Toolkit

An audit is a comprehensive review of a health care provider's records to ensure compliance with state and federal regulations and payer policy. An audit by a state Medicaid program or the Centers for Medicare and Medicaid Services (CMS) may include an examination of documentation, records, billing practices, and payments received.

Each state determines requirements for billing their individual Medicaid program and any of their contracted Medicaid managed care organizations (MCOs). MCOs can be called by different names (e.g., coordinated care organizations, prepaid health plans, care management organizations). They are private companies that contract with state agencies to cover services for enrolled Medicaid beneficiaries in their state.

MCOs are allowed to determine their own qualified providers, and that can sometimes diverge from the state agency’s list (e.g. the state agency may recognize audiology or speech-language pathology assistants but the MCO may not). Billing policies are often detailed in provider handbooks, billing manuals, and/or newsletters. Audiologists and speech-language pathologists (SLPs) are required to comply with the standards set by individual state Medicaid programs in order to be reimbursed for their services.

Heightened scrutiny in the Medicaid program related to the One Big Beautiful Bill Act (OBBBA) has increased the risk of authorization or payment denials, audits, and recoupments for audiology and speech-language pathology services. Documentation deficiencies are a leading cause of these actions.

ASHA’s Medicaid Committee developed this toolkit to provide a practical framework to prepare for potential audits by strengthening documentation, justifying medical necessity, and promoting ethical service delivery.