​The Party's Over – Audits are Back!

The federally declared public health emergency (PHE), set to expire on October 23, was renewed and will remain due to the continued impact of the COVID-19 pandemic. The more relaxed regulatory rules regarding Medicare and Medicaid compliance associated with the PHE is no more, as healthcare provider’s ramp up preparedness with focus on internal processes. 

Healthcare providers have appreciated the more relaxed regulatory rules regarding Medicare and Medicaid compliance associated with the PHE, benefiting from the lapse of Recovery Audit Contractor (RAC), Medicare Administrative Contractor (MAC), and targeted probeane-educate (TPE) audits. It appears the party may be over ─ the audits are back.
 
Unfortunately, many healthcare providers are now experiencing a surge of document requests progressively increasing since August 3, when audits resumed. Though the Centers for Medicare & Medicaid Services (CMS) acknowledged the continuing PHE, a determination was made of the importance to recommence medical review activities, resuming pre-payment and post-payment audits.  Possible CMS targets that providers can expect may include high utilization of particular billing codes or potential fraud in telehealth claims. The agency published five new RAC focus areas on August 3, 2020, including ambulance services, hospital inpatient, hospital outpatient, ambulatory surgical centers, and professional services. This may explain certain increases in medical records requests and overpayment demand letters from RAC contractors and commercial payors in recent weeks.
 
The financial impact of the pandemic on healthcare providers has been significant and the idea of an audit may be dismaying. However, it is wise to remain calm, and not act with haste by unreasonably returning any overpayment. Certainly, validate all overpayments before you accept audit findings by engaging trained staff or third-party vendors to re-audit records determined to have overpayments. Additionally, it is imperative to stay on top of waivers and appropriate use of codes and guidelines. It is important to note, the confirmation process requirements must include all appropriate regulations and payor policies that were active on the date of service.
 
It is expected this upward trend of audits to continue and most likely approach levels not seen before. Providers should have a contingency plan in place on how to manage processes for prevention efficiently and have a well-thought-out plan in responding to the audits.  Proactive measures prove consistently the best approach.
 
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