Payor Disputes and Audits: Observations & Strategies

Courtney Tito, esq., is a member of the Health Law group at McDonald Hopkins, LLC and is located in its West Palm Beach office. This presentation will help participants better understand the payor audit process and prepare the organization to respond. From recognizing the significance of initial correspondence, to responding effectively to initial and subsequent rounds of review, the presentation will take participants through the payor audit process from a government perspective and compare and contrast typical government audits with typical commercial audits. Finally, the presentation will identify some best practices that labs can implement now to prepare for payor audits.


1. Describe the government audit process – from initial correspondence through the various stages of appeal and share speakers’ experience with respect to commercial payor audits – what is similar and what is different from government audits.

2. Discuss the provider’s responsibilities with respect to the medical necessity of testing for which it is submitting claims.

3. Identify steps providers can take to prepare for audits prior to an audit being initiated.