As Center for Medicaid and Medicare Services (CMS) continues to intensify audit activity across hospitals and health systems, organizations are feeling the pressure to strengthen compliance, documentation integrity and revenue cycle accuracy. From Target Probed and Educate (TPE) and Recovery Audit Contractor (RAC) reviews to Unified Program Integrity Contractor (UPIC) and Supplemental Medical Review Contractor (SMRC) investigations, the volume and depth of audits have grown substantially, placing both financial performance and operational stability at risk.
While the regulatory landscape can feel daunting, hospitals have a powerful opportunity to meaningfully reduce audit risk within 90 days through targeted and measurable actions. The key is a structured approach that addresses vulnerabilities in documentation, coding and billing workflows before CMS identifies them.
Below is a framework hospitals can implement immediately to reduce audit exposure and improve compliance outcomes supported by strategies that Windham Brannon Healthcare Consultants bring to every engagement.
- Strengthen Documentation Quality and Clinical Alignment (Days 1-30)
The foundation of audit readiness is defensible, clinically sound documentation. In the first 30 days, hospitals should focus on ensuring that medical records clearly tell the patient’s story and support every service billed. Many audit findings stem from documentation that fails to clearly demonstrate medical necessity, clinical complexity or compliance with Medicare standards. Therefore, establishing strong documentation practices early reduces downstream denials and creates alignment between clinical care, coding and billing. Early efforts should focus on:
- Provider education on medical necessity, including clearly linking the patient’s condition to the services performed.
- Improving therapy, nursing and ancillary documentation to meet Medicare guidelines.
- Validating time-based service documentation, ensuring total time or time in/time out support units billed.
- Aligning clinical and coding language to eliminate discrepancies that trigger denials.
- Perform Focused Coding and Billing Audits (Days 15-45)
Once documentation improvements are underway, hospitals must proactively identify where financial and compliance risk already exists. Focused audits allow organizations to detect patterns before they escalate into payer recoupments or external reviews. By concentrating on high-risk areas rather than on broad, unfocused reviews, teams can quickly uncover vulnerabilities related to coding accuracy, billing practices and documentation sufficiency. Hospitals should initiate:
- Probe audits of high-risk DRGs, diagnoses and procedures
- Therapy coding and documentation reviews
- Edits and denial pattern analysis
- Modifier and time-based billing validations
These audits uncover the root causes of denials such as inadequate documentation, misapplied codes or mismatched billing patterns.
- Implement Corrective Action and Education (Days 30-60)Audit findings only drive improvement when they result in meaningful corrective action. During this phase, hospitals should move beyond identifying issues and begin embedding solutions into daily operations. The goal is not short-term fixes, but sustainable changes that improve compliance, efficiency and claim accuracy across departments. Education, workflow redesign and standardized tools are essential to preventing repeat errors.
Once risk areas are identified, hospitals need structured, sustainable interventions:
- Re-education sessions for clinicians, coders and billers
- Updated documentation templates to mirror CMS requirements
- Process redesign to address workflow gaps
- Real-time quality checks to validate documentation and coding before claims go out the door
- Monitor Progress and Establish Ongoing Controls (Days 60–90)
Long-term audit resilience depends on continuous oversight and measurable performance improvement. In the final phase of the 90‑day plan, hospitals should shift from reactive fixes to proactive monitoring. Establishing clear metrics, routine reviews and internal controls ensures that gains made earlier are sustained, while emerging risks are identified before they result in denials or audits. Hospitals can significantly reduce audit exposure by:
- Tracking improvements in denials, documentation accuracy and coding errors
- Implementing monthly mini-audits for high-risk areas
- Building dashboards that highlight vulnerabilities early
- Establishing a long-term internal audit plan
By the 90-day mark, hospitals should have measurable improvement in compliance strength and a clear roadmap for sustained monitoring.
Why Acting Now Matters
CMS audits are not slowing down, if anything, they’re expanding across service lines, including therapy, inpatient, outpatient and physician services. Hospitals that proactively reinforce compliance are better positioned to:
- Avoid costly recoupments
- Prevent repeat audits
- Strengthen financial performance
- Improve patient care documentation
- Maintain organizational credibility with regulators
A focused 90-day plan can transform a hospital’s audit readiness and significantly mitigate regulatory exposure.
Partner With Windham Brannon Healthcare Consultants
Windham Brannon’s Healthcare Consultants specialize in helping hospitals and health systems strengthen compliance, optimize revenue cycle performance and reduce audit risk. With deep expertise in CMS regulations, clinical documentation, coding and operational improvement, our team provides the insight and practical tools organizations need to stay ahead of regulatory scrutiny.
Whether you are preparing for a TPE review, addressing recent denials or developing a sustainable internal audit strategy, Windham Brannon delivers practical, tailored solutions designed to meet the unique needs of your organization. With a proactive, hands-on approach, we help ensure your hospital is compliant, audit-ready and positioned for long-term operational and financial success.
To learn more about how Windham Brannon’s Healthcare Consulting Team can support your organization, contact your Windham Brannon advisor today or reach out to Denise Gaulin for additional information.
