Warning: Amid the Pandemic Audits Are Coming

Medicare and Medicaid audits to resume Aug. 3, 2020.

The Center for Medicare and Medicaid Services (CMS) suspended audits and medical reviews performed by Medicare Administrative Contractors (MACs) on March 30, 2020 due to the increased pressure on medical providers during the COVD-19 pandemic. This suspension included a temporary pause of prepayment medical reviews conducted by the Targeted Probe and Educate program (TPE) and post-payment reviews.

Last week, however, CMS announced that it plans to resume these enforcement activities on Aug. 3, no matter the status of the pandemic and even as cases continue to rise.

CMS has expressed that the reopening of many states as well as the importance of medical review activities to the CMS program integrity efforts has led them to resuming these types of reviews.

CMS has implied that it will allow for some flexibility with providers facing hardships amid the pandemic. If selected for review, CMS is encouraging providers to discuss with their contractor any COVID-19 related hardships that they are experiencing that could affect audit response timeliness. However, CMS notes that all reviews will be conducted in accordance with statutory and regulatory provisions, as well as related billing and coding requirements. The waivers and flexibilities that were put into place at the time of the dates of service of any claims selected for review will be appropriately considered by the reviewers.

Even when considering the flexibilities with timely responses CMS claims will be put into place, the resumption of audit activities has caused concern among providers who may face an audit during a pandemic. Both staff and patients could be put at risk, as certain staff members will be required to return to the office to pull the necessary documentation for submission. In addition, the resumption of full audit activity will redirect necessary focus away from patients and families amid the pandemic, where providers are already struggling to navigate these unprecedented times while also providing the highest quality care possible.

Providers have also expressed concern that contractors may not be adequately informed regarding the quickly changing regulatory guidance brought on by the pandemic. Many exemptions and waivers regarding payment criteria were issued during this time period, requiring reviewers to learn how to apply these new criteria in just a few short weeks.

The financial burden of an audit is also cause for concern, as many providers have faced significant financial hardship throughout the past few months due to the pandemic. Defending an audit can be a lengthy process and some providers may not be able to withstand the withholds and ultimate overpayments in the current climate.

Providers should be on the lookout for record requests and contact the contractor immediately if the date on the record request is substantially earlier than when the request is received.

Facebook
Twitter
LinkedIn

Related Stories

Leave a Reply

Please log in to your account to comment on this article.

Featured Webcasts

2026 IPPS Masterclass 3: Master MS-DRG Shifts and NTAPs

2026 IPPS Masterclass Day 3: MS-DRG Shifts and NTAPs

This third session in our 2026 IPPS Masterclass will feature a review of FY26 changes to the MS-DRG methodology and new technology add-on payments (NTAPs), presented by nationally recognized ICD-10 coding expert Christine Geiger, MA, RHIA, CCS, CRC, with bonus insights and analysis from Dr. James Kennedy.

August 14, 2025
2026 IPPS Masterclass Day 2: Master ICD-10-PCS Changes

2026 IPPS Masterclass Day 2: Master ICD-10-PCS Changes

This second session in our 2026 IPPS Masterclass will feature a review the FY26 changes to ICD-10-PCS codes. This information will be presented by nationally recognized ICD-10 coding expert Christine Geiger, MA, RHIA, CCS, CRC, with bonus insights and analysis from Dr. James Kennedy.

August 13, 2025
2026 IPPS Masterclass 1: Master ICD-10-CM Changes

2026 IPPS Masterclass Day 1: Master ICD-10-CM Changes

This first session in our 2026 IPPS Masterclass will feature an in-depth explanation of FY26 changes to ICD-10-CM codes and guidelines, CCs/MCCs, and revisions to the MCE, presented by presented by nationally recognized ICD-10 coding expert Christine Geiger, MA, RHIA, CCS, CRC, with bonus insights and analysis from Dr. James Kennedy.

August 12, 2025

Trending News

Featured Webcasts

The Two-Midnight Rule: New Challenges, Proven Strategies

The Two-Midnight Rule: New Challenges, Proven Strategies

RACmonitor is proud to welcome back Dr. Ronald Hirsch, one of his most requested webcasts. In this highly anticipated session, Dr. Hirsch will break down the complex Two Midnight Rule Medicare regulations, translating them into clear, actionable guidance. He’ll walk you through the basics of the rule, offer expert interpretation, and apply the rule to real-world clinical scenarios—so you leave with greater clarity, confidence, and the tools to ensure compliance.

June 19, 2025
Open Door Forum Webcast Series

Open Door Forum Webcast Series

Bring your questions and join the conversation during this open forum series, live every Wednesday at 10 a.m. EST from June 11–July 30. Hosted by Chuck Buck, these fast-paced 30-minute sessions connect you directly with top healthcare experts tackling today’s most urgent compliance and policy issues.

June 11, 2025
Open Door Forum: The Changing Face of Addiction: Coding, Compliance & Care

Open Door Forum: The Changing Face of Addiction: Coding, Compliance & Care

Substance abuse is everywhere. It’s a complicated diagnosis with wide-ranging implications well beyond acute care. The face of addiction continues to change so it’s important to remember not just the addict but the spectrum of extended victims and the other social determinants and legal ramifications. Join John K. Hall, MD, JD, MBA, FCLM, FRCPC, for a critical Q&A on navigating substance abuse in 2025.  Register today and be a part of the conversation!

July 16, 2025

Trending News

Happy National Doctor’s Day! Learn how to get a complimentary webcast on ‘Decoding Social Admissions’ as a token of our heartfelt appreciation! Click here to learn more →

CYBER WEEK IS HERE! Don’t miss your chance to get 20% off now until Dec. 2 with code CYBER24