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The HCA strives to work together with our providers and provide education about program integrity.

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Provider resources

Frequently asked questions (FAQs)

  • Desk audits and reviews
  • Onsite audits
  • Data mining
  • Algorithms
  • Site visits
  • CMS Medicaid Integrity Contractor (MIC) audits
  • CMS Payment Error Rate Measurement (PERM) reviews
  • Health & Human Services (HHS) Office of Inspector General (OIG) audits
  • Medicaid Recovery Audit Contractor (RAC) audits
  • Providers will typically receive written notification by certified mail from the Section of Program Integrity (PI)
  • Providers may receive an overpayment notice if an algorithm or data review identifies overpayments.
  • As authorized by WAC 182-502A, unannounced visits may occur.
  • Algorithms
  • 100 percent review of a provider's claims for a specific period
  • Random stratified or non-stratified sample of claims for a specific time period
  • Criteria-driven selection of specific claims for a specific time period

Providers must retain documentation that supports the services billed to the HCA. PI may request the following types of information and records; please note that this is not an all-inclusive listing:

  • Appointment books/patient sign-in sheets.
  • Coding summary.
  • Complete hospital medical records.
  • Core Provider Agreement.
  • Credit balance reports.
  • Dental x-ray films.
  • Diagnostic test results (e.g. lab reports, radiology/nuclear medicine reports, etc.).
  • Durable & non-durable medical equipment/product delivery documents.
  • Financial reports/accounting/billing records, charge masters, service level descriptions.
  • Invoices.
  • Medication administration records/sheets.
  • Office/facility policies/employment records.
  • Office visit/hospital visit notes.
  • Ownership agreement/business licenses and professional staff licenses/certificates.
  • Patient care plans.
  • Physician/practitioner orders.
  • Prescription records.
  • Proof of delivery documents.
  • Surgical, recovery and anesthesia records.
  • Transfer records/referral documents.
  • Treatment records.

Providers must maintain appropriate documentation in the client's medical or health care service records for 6 years.

Please see WAC 182-502-0020.

Audit staff will either make copies or request copies be made of original provider records and/or information.
No, WAC 182-502A-0401(11) states "The agency does not reimburse the costs an entity incurs complying with program integrity activities."
  • Provide a workspace or room, with table and chairs and adequate electrical outlets for audit equipment.
  • Have key office staff available during the audit for the audit team to interview.
  • If medical records are requested in advance, please have records in alphabetical order placed in the designated workspace for the auditors.
  • Have copies of current business license(s) and professional healthcare licenses of all pertinent staff available for the auditors.
  • A provider may informally dispute a draft audit report or preliminary review notice within 30 days from receipt of the report or notice. See WAC 182-502A-0801.
  • A provider may request an administrative hearing to formally appeal a final audit report or notice of improper payment within 28 days from receipt of the report or notice. See WAC 182-502A-0901 and RCW 41.05A.170.
  • A provider may informally dispute and formally appeal an algorithm overpayment notice. To formally appeal, a provider must request an administrative hearing within 28 days from receipt of overpayment notice. There is not a separate time period to submit an informal dispute. Therefore it must also be received within 28 days of receipt of an algorithm overpayment notice. See WAC 182-502-0230 and RCW 41.05A.170.
  • When an audit or review is in the draft or preliminary state, a provider may contact the auditor to request an extension.
  • If the provider has received a final audit report, notice of improper payment or overpayment notice, no extension is allowed. See RCW 41.05A.170.
  • Department of Social and Health Services (DSHS) Office of Financial Recovery
  • Department of Health
  • Attorney General's Office
  • Medicaid Fraud Control Unit
  • Other stakeholders as appropriate
  • WAC 182-502A-0701 allows referral for disciplinary or criminal action if warranted