Contractors ‘flip switch’ on audits

YARMOUTH, Maine – After lying largely dormant during the public health emergency, audits are on the rise, including for respiratory claims, say industry consultants. 

While audits never stopped completely during the PHE, waivers of certain coverage criteria, including for oxygen equipment and CGMs, helped lessen the burden on providers. But UPIC auditors are now increasingly targeting claims covered by those waivers, says Kelly Grahovac.  

“It’s almost like they flipped the switch,” said Grahovac, general manager of Atlanta-based The van Halem Group. “With the UPICs, they are looking at respiratory claims that occurred within PHE dates of service and that have the CR modifier. We are seeing a lot of denials for medical necessity, so it’s almost as if they are ignoring the CR modifier.” 

The PHE, currently set to expire Jan. 11, is expected to be extended for another 90-day period. 

Other audits are also ramping up, says Ronda Buhrmester. For example, the MACs are doing TPE audits for product categories that are not typically targeted, like commodes. 

“Hey, they are not looking at respiratory, so why not commodes,” said Buhrmester, senior director of payer relations and reimbursement for VGM & Associates. “Suppliers need to be mindful that it doesn’t matter what the category is – they are always at risk.” 

As providers prepare for the shift to a post-PHE environment, those that looked beyond the pandemic will be better prepared for whatever comes down the pike, says Grahovac. 

“I’ve spoken with some who took the time during the reprieve (from audits) to home in on their compliance programs and do their own internal audits,” she said. “But I’ve also heard from others that have said, ‘Oh we’ve been putting that CR modifier down to push (the order) out the door. It comes down to the provider and how thoughtful they are with their compliance.”