Resources · Audits
What happens during an adult day care Medicaid audit?
Short answer
Medicaid audits of adult day programs are typically run by a UPIC, RAC, or Medicaid Fraud Control Unit, which requests a sample of claims — often thirty or more — and checks each one against documentation like attendance records and signatures. Gaps found in that sample are frequently extrapolated across your full billing history, not just the claims reviewed.
Who conducts these audits
UPIC
Unified Program Integrity Contractors review Medicaid and Medicare claims for improper payments on behalf of CMS.
RAC
Recovery Audit Contractors identify and recover improper Medicaid payments, often working from sampled claims.
MFCU
State Medicaid Fraud Control Units investigate provider fraud and patient abuse, and can refer cases for criminal charges.
The mechanic that matters most
How a sample becomes a bigger finding
These auditors don't typically review every claim you've ever billed. They pull a sample — often thirty or more claims — from your billing history and check each one for documentation: proof the member was present, the exact time, and some form of signed or verified confirmation.
If the sample turns up claims that can't be documented, the finding doesn't usually stay contained to those few claims. Auditors commonly extrapolate the error rate found in the sample across your entire billed population for the period under review — so a handful of missing sign-ins can turn into a disallowance on claims you were never individually asked to prove.
Not hypothetical
What a real audit found
On February 19, 2026, the New York State Comptroller released an audit of the state's social adult day care (SADC) program that identified $285 million in improper payments, including $672,147 disallowed at three facilities that lacked proper sign-in sheets. One Flushing center had billed for 530 participants in a single day against a 323-person capacity. The audit recommended uniform recordkeeping standards statewide.
The wider environment — sober framing, not a scare tactic
What's being enforced beyond routine audits
Adult day billing is under more scrutiny nationally than it was a few years ago. A CBS News investigation reported that social adult day care Medicaid billing reached $3.35 billion nationwide in 2024, and that New York's Department of Health has referred 387 centers for investigation since 2021. In New Jersey, the state Comptroller found 21 adult medical day care providers improperly billed a combined $946,000 across more than 11,000 violating claims, including instances of billing while a beneficiary was hospitalized.
These are findings and charges against specific operators, not a suggestion that audits assume wrongdoing. The centers most affected by this climate are usually the honest ones — the ones whose only real gap is a paper sign-in sheet standing in for proof it was never built to provide.
What tends to hold up under a sample request
Per-member, per-date records
A record tied to one specific member and one specific date, not a roster or a general schedule, is what a sample request actually asks for.
A record that can't be quietly changed
Whatever format you use, the strongest answer to an auditor's question is a record that was created the day it happened and hasn't been editable since.
Audit procedures, sample sizes, and the specific documentation an auditor requests vary by state, program, and payer. This page describes general mechanics and specific, dated findings we've reviewed — it is not legal advice and isn't a substitute for guidance from your own state Medicaid agency, managed care plan, or counsel.
Medicaid audits — frequently asked
Reviews commonly come from a Unified Program Integrity Contractor (UPIC), a Recovery Audit Contractor (RAC), or a state's Medicaid Fraud Control Unit (MFCU). State comptrollers also run their own oversight audits — New York's State Comptroller is the clearest recent example we've reviewed.
Sample audits often start with thirty or more claims drawn from your full billing history, not a review of every claim you've ever submitted. The reviewer is testing whether your recordkeeping holds up, not trying to catch every possible problem in one pass.
Auditors frequently extrapolate the error rate found in the sample across your entire billed population for the period under review. That means a handful of undocumented days can turn into a disallowance covering claims you were never individually asked to prove.
No. The New York State Comptroller's February 2026 findings were about recordkeeping — sign-in sheets that didn't meet the standard needed to support billed claims — which is a different category from the criminal fraud cases prosecutors have separately brought. Most documentation gaps are a recordkeeping problem, not evidence of intent.
Audits aren't limited to large, multi-site operators. The New York Comptroller's February 2026 audit specifically named findings at individual facilities, including the $672,147 disallowance across three centers for inadequate sign-in sheets. Size alone doesn't determine whether a program gets reviewed.
Have proof ready before an auditor asks
A per-member, per-date evidence packet — timestamps, signatures, and face-match confidence where used — assembled from records that already existed.