What happens if I fail an audit or my documentation is not enough?
The state can deny or take back payment for visits it cannot support, require a corrective action plan, or take adverse action such as suspending referrals. Falsifying records is treated as fraud. Federal reviewers have recommended recovering payments for claims with missing proof. Respond fast and in writing.
Weak documentation has a price. It is usually money, and sometimes your standing in the program.
What the sources show:
- A federal review found claims improper where worker qualifications or service records were missing, and recommended that payments be recovered.
- Georgia’s CCSP and SOURCE manual lists reasons for adverse action. They include failing to give services as the care plan requires, failing to turn in a corrective action plan or requested documents on time, refusing state access to records, and falsifying records.
- Georgia says utilization review reports and other audits can show a pattern of noncompliance.
If you get an audit letter:
- Read the deadline and put it on your calendar.
- Send exactly what was asked, by the method asked.
- Never change or backdate a record.
- Fix the system, then write the corrective action plan.
- Ask a health care attorney before you reply to anything involving possible repayment or fraud.
This answer is general information, not legal advice.
Sources
- Inappropriate Payments for Medicaid Personal Care Services (OEI-07-08-00430) · HHS Office of Inspector General
- EDWP: CCSP and SOURCE General Services manual (Q3 July 2026) · Georgia DCH / GAMMIS
Reviewed by Beth Bledsoe, Care Business Advisor®, 28 Oct 2026. Rules change. Confirm with your state Medicaid agency before you act.
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