Return of the Audits By Wayne van Halem, AHFI, CFE, President of The van Halem Group
Very quietly in a document released in July, ironically entitled “Coronavirus Disease 2019 (COVID-19) Provider Burden Relief Frequently Asked Questions (FAQs),” CMS announced that audits will resume on Aug. 3, 2020 regardless of the state of the Public Health Emergency (PHE). This news took quite a few by surprise, including me. While we all knew audit activity would not be ceased forever, all the other waivers that CMS announced were to be in place for the duration of the PHE, which is still in effect now through the end of September. I guess many of us assumed that would be the case with audits as well.
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We also learned that Targeted Probe and Educate (TPE) Prepayment reviews, the most common type of review pre-pandemic, would not be a part of this initial audit phase. The reason being is that CMS indicated that (1) they do not want to hold up payments to providers, and (2) due to claim processing system limitations, there are less flexibilities to grant extensions for those providers that would need more time to respond. What they mean by this specifically is that with prepayment reviews, if no documentation is received by the due date, the system will automatically deny the claim.
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Providers are still struggling to take care of their patients, deal with equipment inventory issues, and maintain the safety and well-being of their employees.
Another reason many of us were caught off-guard is the fact that at the time of this announcement in July, and even today, many parts of the U.S. are still dealing with large numbers of COVID patients and increased hospitalizations. Providers are still struggling to take care of their patients, deal with equipment inventory issues, and maintain the safety and well-being of their employees. To confound the situation, many organizations are struggling with the reality that the billing or administrative staff that would normally handle audit responses are working remotely, making the accessibility to mail and patient records even more difficult. After this announcement, I had an opportunity to meet with representatives of CMS Central Office to discuss their plan for the return of audits. We learned that while the date to begin medical review functions is Aug. 3, there will likely be a delayed time frame before audit requests officially go out. During the July meeting, CMS was still working to develop instructions for contractors. They indicated that they had no intention of opening up the flood gates for a large volume of audits, but rather, they described their strategy as a “toe in the water” type of approach. In a later publication on Aug. 6, they indicated medical review activities would begin on Aug. 17.
We can be looking at large overpayments that must then be fought through the often lengthy and frustrating appeals process.
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A main area of concern though is the impact that post-payment audits have. While I appreciate CMS not wanting to hold up a provider’s payments, asking for refunds on claims that have been paid is equally, if not more, damaging. In this environment, many providers are already financially impacted by the fact that many patients are no longer going to see their doctors or having surgical procedures, both of which are big sources of referrals. Also, what CMS did not indicate is whether these post-payment reviews will be on a single claim or a sample of claims. If it is a sample of claims, we can be looking at large overpayments that must then be fought through the often lengthy and frustrating appeals process. CMS has directed audit contractors to only review claims submitted prior to March 1, 2020. CMS also indicated that they do intend to audit claims submitted during the PHE at this particular time. I would imagine that later, claims during the pandemic will be analyzed by CMS. For this reason, it is necessary to remind everyone that the claims you submit are always open to scrutinization, and those submitted during the pandemic will be no exception. CMS has not provided any details as to whether there will be a requalification process for patients whose claims may not have otherwise met the requirements had they been submitted outside 7
