01/01/2026    Name Withheld

Asking Medicare About Your Billing Profile

I remember reading a query on PM News about
providers requesting their billing profile
information from local Medicare carriers. This
information consists of the providers patient
billings to Medicare as compared to their fellow
piers. I am not offering advice about requesting
this. I am only sharing my experience with
Medicare after I requested this information.

Several years ago, I was involved in a statewide
audit in Florida from First Coast Medicare
relating to codes billed for painful corns and
calluses. I had a very busy Medicare practice and
used these codes frequently when my patients
symptoms and criteria reflected the use of these
codes. The audit involved several hundred
podiatrists in Florida. While Medicare always
advises providers to follow the published LCD
requirements to justify billing a particular code,
they literally changed the qualifying LCD
requirements of these codes midstream and held
providers accountable.

Medicare sent out hundreds of recoupment letters
that demanded immediate payment. FPMA became
involved and got an injunction against First Coast
Medicare, stopping recoupment and demanding
Medicare to reinstate the original LCD
requirements. The final result of this audit was
that Medicare recouped zero dollars at a cost of 6
million dollars to taxpayers.

Several weeks later, I attended a seminar about
Medicare billing. The lecturer advised us to
contact our local Medicare carrier and ask for our
billing profile to see where we stand in relation
to our peers. I took that advice and requested
this information which Medicare promptly sent out.
About one month later, I received a post-payment
audit from Medicare concerning another procedure
code. It led to a recoupment letter from Medicare
for a little more than $10,000. I went with legal
representation to the Medicare headquarters in
Jacksonville, Florida to dispute this. I
successfully defended this audit and received my
money back from Medicare.

My adventure did not end. Soon after successfully
defending that last audit, I received a letter
from Medicare requiring me to include patient
notes with each claim I billed for a period of 30-
60 days . My documentation and treatment met
Medicare’s criteria and I was paid on all of the
claims for the various procedures I did. They
lifted this requirement in thirty days. Since
then, I have successfully defended any other pre-
payment audits I got from Medicare.

Whether or not requesting your billing profile
from the local Medicare carrier in your state is
the proper thing to do, it proved not to be
advantageous in my case. My only suggestion is
that your billing should be conservative and
corresponding to the LCD guidelines of your local
Medicare carrier.

Name Withheld

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