Medicare audit letters: what PT/OT practices need to gather for each claim
Stephen Grinich
HealthSpark CEO and Founder••6 min read
What do you need to gather for a Medicare audit letter?
The documentation behind the claim it names: the evaluation, the signed plan of care, any recertifications, progress reports, and the daily notes for those dates of service. Check everything for missing signatures and gaps, then draft a short response letter to Medicare that goes out with it.
With a batch, you do that for every letter. The work isn't knowing what to send. It's finding it all, letter after letter.
- Each letter is about one claim. Gather the documentation for that patient and those dates, not the whole chart.
- For PT/OT, that is usually the evaluation, plan of care, recertifications, progress reports, and daily notes.
- Before sending, check for missing signatures, missing plans of care, missing notes, and documentation gaps.
- Draft a response letter for each claim that lists what's enclosed and where it supports the services billed.
- A batch is slow because every letter means working through the pile and pulling records together again.
What to gather for each claim
Each audit letter names a patient, a claim, and the dates of service Medicare is reviewing. Your job is to show the care on those dates was planned, certified, and documented. For a PT/OT claim, that means:
| Document | What to check before you send it |
|---|---|
| Evaluation | Signed and dated, and it supports the plan of care that followed. |
| Plan of care | Signed by the physician or NPP, covering the dates of service under review. |
| Recertifications | Any time the plan was extended, the recertification is there and signed. |
| Progress reports | Written as the plan went on, not missing for a stretch of visits. |
| Daily notes | One for every date of service on the claim, signed by whoever treated. |
| Referral or order | If the patient came with one, include it. |
The letter itself lists what it wants. Use this as the checklist for what that usually turns out to be.
Check for gaps before you send
Once the documentation for a claim is together, read through it for anything you need to fix before responding:
- Missing signatures
- Missing plans of care
- Missing notes
- Documentation gaps
- Deadlines
A plan of care that was never signed, or a note with no signature, is far easier to deal with now than after Medicare asks about it.
Draft the response letter
Each packet goes back with a short letter to Medicare. It doesn't need to be long:
- The patient, claim, and dates of service it responds to
- A list of the documents enclosed
- Where in those documents the reviewer can see each service was planned, certified, and documented
- An explanation of anything unusual, like a late signature or a gap in visits
Put a copy of the audit letter first, then your response letter, then the records.
Why a batch takes so long
Knowing what to send is the easy part. The hard part is that the records are rarely in one place. Some are in your EHR, some came back by fax, some are on paper. A batch means someone first works through a pile of letters just to figure out what each one is, then spends hours pulling records together and writing a response letter for every one of them.
How HealthSpark handles audit letters
HealthSpark gives your practice a virtual address. All of your mail goes to a virtual mailbox and is scanned into HealthSpark automatically.
Our AI agent reads every letter as it comes in. When one is a Medicare audit, open it and ask the agent to find all the faxes and documents for it. The agent works out what Medicare is asking for, pulls the relevant records from your notes and fax history, and drafts the response letter to Medicare.
It also flags anything to fix before you respond, like missing signatures, plans of care, notes, documentation gaps, or deadlines.
So instead of working through a pile of letters and spending hours pulling records together, you review the records and the drafted letter in a few minutes, fix what it flagged, and fax it out. See how the virtual address works.
- EvaluationJun 12
- Plan of careJun 12
- Progress reportJul 17
- Visit notes (6)Jun 12 to Aug 21
- RecertificationAug 28
- Response letter to MedicareDrafted
Why it helps to have every letter scanned in and readable by AI
The audit response is the obvious win, but the bigger change is the pile itself. When the agent is watching the entire stream of incoming mail, nobody has to work through the pile first just to figure out what each letter is.
Every letter is also kept as a written record, attached to the right patient, and searchable. When you need an old letter, you ask for it instead of digging through a box.
Frequently asked questions about Medicare audit letters
What documents does Medicare ask for in a PT/OT audit?
Do I send the whole chart?
What if a signature is missing or can't be read?
Do I need to write a letter back to Medicare?
How long do I have?
Sources
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