Heartland Session Sneak Peek: Audits During and Post Pandemic: What Should We Expect?

Published in Member Communities on August 04, 2021

It has been nearly 17 months since the Centers for Medicare and Medicaid Services (CMS) declared COVID-19 a national emergency, and with that declaration a variety of waivers and flexibilities were put into effect that allowed health care providers to adequately care for patients amidst a pandemic. Of these was the halting of all CMS audits for Medicare and Medicaid claims. In August of 2020, CMS reinstated audit program functions, and instructed the MACs to conduct audits on a post-payment basis for claims with dates of service prior to March 1, 2020. At that time, CMS described the return of audits as a “toe in the water” approach, alluding to the fact that audit activity would have a slow start.  

What followed that announcement in late summer of 2020 was the MACs revisiting the “pre-TPE audit” days, initiating widespread probe reviews on post-payment claims. The product categories weren’t unfamiliar, with orthotics taking center stage. Since then, other familiar product categories such as manual wheelchairs, surgical dressings and urological supplies have been added to the list, as well as some outliers, like osteogenesis stimulators. However, while the MACs were continuing to audit the pre-pandemic dates of service, the RAC and SMRC jumped in, with no exclusions on pandemic claims, and, with no exemption of claims in the respiratory category. In fact, in October of 2020, the SMRC was conducting a review project on ventilator claims, at the direction of the CMS’ Program Integrity Group.  

Fast-forward to June 3, 2021, when CMS announced that MACs could begin conducting post-payment reviews for dates of service on or after March 1, 2020. Essentially, everything is fair game at this point, but the pandemic health emergency (PHE) rules (i.e. waivers and flexibilities) are still applicable, as the PHE was extended another 90 days and likely will be again through the end of this year. In addition to the MAC and SMRC audits, the RAC has shown an increase in audit activities, as have the UPICs and most state Medicaid plans. Commercial plan audits have also been on the rise, though they were under no directive to cease or slow audit functions at any time during the PHE. It appears that audits are back and accelerating at a pace most of us in the industry haven’t seen since 2017 and the emergence of the RAC program.  

Heartland Featured Session 

Join The van Halem Group’s Kelly Grahovac and Wayne van Halem during this session where they will discuss the contributing factors to the rise in audits and how suppliers can be ‘audit-ready’. Don’t miss this informative session to learn about how to prepare for audits of your DMEPOS claims and also what to expect for the remainder of 2021 and beyond. Learn more and register at www.vgmheartland.com.  


TAGS

  1. audits
  2. conference
  3. heartland
  4. hme
  5. the van halem group
  6. tradeshow
  7. vgm

From Our Experts

A Letter From the President: June 2025 thumbnail A Letter From the President: June 2025 Lindy Tentinger shares information on the VGM Heartland Conference, competitive bidding, new tools, and more. The Latest in Billing & Reimbursement from Ronda Buhrmester: Oxygen Equipment Updates and Reminders thumbnail The Latest in Billing & Reimbursement from Ronda Buhrmester: Oxygen Equipment Updates and Reminders Ronda Buhrmester, Sr. Director of Payer Relations and Reimbursement, shares updates on oxygen equipment groups. Maximize Your Heartland Experience: Tips, Tools, & Must-Knows thumbnail Maximize Your Heartland Experience: Tips, Tools, & Must-Knows Here's everything you need to know to ensure a smooth, successful, and unforgettable Heartland experience. Maximize Your Heartland Experience: Tips, Tools, & Must-Knows thumbnail Maximize Your Heartland Experience: Tips, Tools, & Must-Knows Here's everything you need to know to ensure a smooth, successful, and unforgettable Heartland experience. 2025 O&P Woman of the Year Nominations Now Open thumbnail 2025 O&P Woman of the Year Nominations Now Open The nomination period for the 2025 O&P Woman of the Year Award is open now through July 11. This award is open to all women who work in the O&P profession. Understanding the Value of ATP Certification and ATP Academy thumbnail Understanding the Value of ATP Certification and ATP Academy Becoming an ATP is a popular path often taken by occupational therapists (OTs), physical therapists (PTs), occupational therapy assistants (OTAs), physical therapy assistants (PTAs), and wheelchair technicians. With an ATP certification, one can both fill the needs of suppliers to sell certain wheelchairs and demonstrate that they have the skills and knowledge to complete their job as defined by the leading authority in the credentialing industry. Mobility Awareness Month: Celebrating the Impact of Mobility Providers thumbnail Mobility Awareness Month: Celebrating the Impact of Mobility Providers May is Mobility Awareness Month, a time recognizing the importance of mobility solutions, the professionals who provide them, and those who rely on them. Mobility Awareness Month: Celebrating the Impact of Mobility Providers thumbnail Mobility Awareness Month: Celebrating the Impact of Mobility Providers May is Mobility Awareness Month, a time recognizing the importance of mobility solutions, the professionals who provide them, and those who rely on them.