Warning: Amid the Pandemic Audits Are Coming

Medicare and Medicaid audits to resume Aug. 3, 2020.

The Center for Medicare and Medicaid Services (CMS) suspended audits and medical reviews performed by Medicare Administrative Contractors (MACs) on March 30, 2020 due to the increased pressure on medical providers during the COVD-19 pandemic. This suspension included a temporary pause of prepayment medical reviews conducted by the Targeted Probe and Educate program (TPE) and post-payment reviews.

Last week, however, CMS announced that it plans to resume these enforcement activities on Aug. 3, no matter the status of the pandemic and even as cases continue to rise.

CMS has expressed that the reopening of many states as well as the importance of medical review activities to the CMS program integrity efforts has led them to resuming these types of reviews.

CMS has implied that it will allow for some flexibility with providers facing hardships amid the pandemic. If selected for review, CMS is encouraging providers to discuss with their contractor any COVID-19 related hardships that they are experiencing that could affect audit response timeliness. However, CMS notes that all reviews will be conducted in accordance with statutory and regulatory provisions, as well as related billing and coding requirements. The waivers and flexibilities that were put into place at the time of the dates of service of any claims selected for review will be appropriately considered by the reviewers.

Even when considering the flexibilities with timely responses CMS claims will be put into place, the resumption of audit activities has caused concern among providers who may face an audit during a pandemic. Both staff and patients could be put at risk, as certain staff members will be required to return to the office to pull the necessary documentation for submission. In addition, the resumption of full audit activity will redirect necessary focus away from patients and families amid the pandemic, where providers are already struggling to navigate these unprecedented times while also providing the highest quality care possible.

Providers have also expressed concern that contractors may not be adequately informed regarding the quickly changing regulatory guidance brought on by the pandemic. Many exemptions and waivers regarding payment criteria were issued during this time period, requiring reviewers to learn how to apply these new criteria in just a few short weeks.

The financial burden of an audit is also cause for concern, as many providers have faced significant financial hardship throughout the past few months due to the pandemic. Defending an audit can be a lengthy process and some providers may not be able to withstand the withholds and ultimate overpayments in the current climate.

Providers should be on the lookout for record requests and contact the contractor immediately if the date on the record request is substantially earlier than when the request is received.