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.  


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