Instead of “Love in the Time of Cholera,” we are currently living through “Audits in the Time of COVID.”
The period we are all still facing has been dubbed, legally, a public health emergency, or PHE (not to be confused with PPE). The Centers for Medicare & Medicaid Services (CMS) has loosely defined what a PHE is – but the definition is fluid. As of now, CMS is defining it as the period of time between Jan. 27, 2020, and a date to be determined. It includes today and is ongoing.
Dear all, COVID-19 is really not over! The defined period of the PHE has yet to be definitively defined.
Audits are being restarted. There is no doubt. The dates of service that will provide the most confusion in Recovery Audit Contractor (RAC) and Medicare Administrative Contractor (MAC) audits will be Jan. 27, 2020 through June 8, 2020. In the future, when you receive document requests for dates of service in 2020, tread lightly and carry a big stick.
CMS’s RAC program’s mission is to identify and correct improper Medicare payments through on-site and desk review audits, and to detect and collect overpayments made on claims of healthcare services reimbursed for services rendered. The 2020 executive summary forecasting how audits would be conducted in 2020 was published in December 2019. There may have been some variables since its publication, like COVID-19.
For those 1.2 million providers participating in Medicare Quality Payment Programs and on the front lines of America’s fight against COVID, the quality reporting guidelines have been suspended. You were given reprieve from quality reporting, but it will not include a stay from RAC and MAC audits targeting dates of service during the PHE.
Medicare Appeals in Fee-for-Service (FFS), Medicare Advantage (MA), and Part D
CMS is allowing MACs and qualified independent contractors (QICs) in the FFS program and the Medicare Advantage and Part D Independent Review Entities (IREs) to waive requests for timeliness requirements for additional information to adjudicate appeals.
CMS is also allowing Medicare provider appeals to be processed:
Medicaid also has implemented waivers that differ from state to state during the PHE.
The following are examples of flexibilities that states and territories may seek through a Section 1135 waiver request:
Check your state for all newly waived exceptions during this public health crisis.
Time-stamp all research so you will be prepared to argue before a judge that whatever day is at issue falls within the definition of the PHE. Because during the PHE, the exceptions define the rules.
Programming Note: Knicole Emanuel is a permanent panelist on Monitor Mondays. Listen to her live reporting every Monday at 10 a.m. EST
Picture this: You are driving through an area you don’t know well. It is a cold day. You stop to get gas. You fill the
Welcome back everybody after the holidays. As a CPA, I have always been uncomfortable when the word “Audit” is used to describe activity since the term
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