A new, but temporary, era in audits

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Friday, July 24, 2020

WASHINGTON – Industry stakeholders now have a better idea of CMS’s plans for restarting program integrity activities on Aug. 3, but they still have questions, like what product categories will get audited. 

On that matter, stakeholders will be watching the RAC and SMRC contractors for clues, as they now post active audits to their web sites. 

“We do have transparency in that,” said Andrea Stark, a reimbursement specialist for MiraVista. “The DME MACs may or may not announce reviews in advance. I’m curious to see if the MACs will return to widespread audits based on targeted codes.” 

Both AAHomecare and the van Halem Group last week shared new details from CMS about the impending audits, like how the agency will take a phased approach, starting with RAC audits and then moving to SMRC audits, both of which have been on pause since March due to the public health emergency. 

That phased approach, as well as CMS’s decision to give providers extensions in responding to audits and even cancelling audits based on their ability to respond, begs the question: Will it be business as usual for the contractors? Probably not. 

“Responding to audits is really the last thing on the minds of providers, especially in areas hit hard (by COVID-19), where the focus is on getting patients what they need,” said Kelly Grahovac, general manager for the van Halem Group. “(The contractors) are going to ease into this.” 

That focus on getting patients what they need is a big reason for another new detail: CMS will focus on post-payment audits and not pre-pay audits and, therefore, TPE audits will not be restarted at this time. Will that mean, however, that more providers will be impacted by audits?  

“With the targeted nature of TPEs, fewer suppliers were impacted directly; with post-pay audits, depending on the volume and scope, more suppliers could be impacted,” Stark said. 

Another new detail that raises questions: CMS won’t focus on claims started during the public health emergency, essentially narrowing audits to January and February, but for how long? 

“That would surprise me, if they maintain that position for a long time,” Stark said. “There are data anomalies unique to the pandemic, and they’re going to have to look at those claims. It’s definitely going to be a new level of auditing due to the nuances of how they determine baseline medical necessity (with relaxed regulations), but they’re going to have to come up with an approach that protects the Medicare Trust Fund by weeding out the bad actors without derailing the suppliers acting in good faith.” 

Stakeholders weren’t necessarily surprised by CMS’s decision to restart audits, an announcement that was tucked into a recent update of the COVID-19 Provider Burden Relief FAQ. The agency is paying contractors to perform these activities.   

“They can’t do nothing forever,” said Kim Brummett, vice president of regulatory affairs for AAHomecare.