At Palmetto GBA, the Audit and Reimbursement Department plays a vital role in protecting the financial integrity of the Medicare program. Their mission? To make sure every Medicare dollar is used appropriately—and that healthcare providers are reimbursed fairly and in full compliance with federal regulations. In pursuit of excellence, the department embraces innovation and maintains the highest auditing standards.

What the Team Does

The Audit and Reimbursement Department’s primary responsibilities include:

• Reviewing Medicare cost reports submitted by providers
• Conducting desk and field audits
• Verifying financial and statistical data
• Ensuring compliance with government auditing standards

They work with a wide range of providers, from small practices to large teaching hospitals and organ acquisition facilities, requiring analysis and interpretation of complex financial documentation.

Reimbursement Functions

Every year healthcare providers must submit their cost reports that include all their Medicare claim submissions and payments received during the prior fiscal year. These reports are typically hundreds of pages long.

Once received, the Reimbursement team performs a review and analysis of the data, verifying payment and bad-debt data. This process ends in a tentative settlement.

Auditing Functions

Once a tentative settlement is issued, Reimbursement hands the cost reports over to Auditing for desk reviews and audits based on guidance from the Centers for Medicare & Medicaid Services.

The Auditing Department works in teams that include a lead auditor, auditor III, auditor II, auditor I, lead accounting technician and an intern.

The Auditing teams take a deep dive into the cost reports. Reviews can take as little as eight hours or more than 200 hours depending on the size of the organization and the complexity of the cost report. Audits of complex reports require deeper analysis, research and detective work. After a thorough review, auditors gather their evidence, write a detailed determination of their findings and issue a final settlement notice.

Educating Providers

A key part of the department’s mission is to help providers understand Medicare rules and improve their reporting accuracy. This proactive support streamlines processes, reduces errors and lowers costs across the healthcare system.

Beyond their core functions, team members contribute to training, mentoring and process improvement initiatives, helping drive smarter, data-informed decisions across the healthcare system. Through collaboration with other functional areas, the team members gain valuable experience and exposure to complex healthcare finance systems.

Medicare Oversight and Accountability

Palmetto GBA’s Audit and Reimbursement Department is essential to the health and long-term viability of the Medicare program. Through meticulous cost report reviews, rigorous audits and proactive provider education, the team ensures that Medicare funds are used appropriately, and providers are reimbursed accurately. Their commitment to excellence, collaboration and continuous improvement strengthens the integrity of the healthcare system and safeguards the Medicare trust funds.