CMS Audits to Resume Even in the Midst of the Public Health Emergency

In case you missed it, CMS released the Coronavirus Disease 2019 (COVID-19) Provider Burden Relief Frequently Asked Questions (FAQs) updated July 7, 2020. In this release, CMS indicates that they are discontinuing the suspension of medical reviews that was imposed on March 30 because of the COVID-19 pandemic. In typical CMS-speak, the FAQ states “CMS expects to discontinue exercising enforcement discretion beginning August 3, 2020, regardless of the status of the public health emergency.” In plain speak, CMS will no longer stop the RACs and MACs from performing medical review audits, even if the public health emergency is still in place, which I expect it will be. It’s interesting to note that CMS is rescinding the suspension on audits based on the importance of performing medical review activities along with the fact that states are reopening. That might be a bit premature as we’ve seen that many states that reopened are now reconsidering those decisions as coronavirus cases are spiking at an unprecedented rate. Nevertheless, I doubt CMS will reconsider its decision to reopen medical reviews.

CMS recommends if you are experiencing COVID-19-related hardships that could affect the timeliness of responding to audits you discuss that with your Medicare Administrative Contractor (MAC). I would recommend you do that now and not wait for the audits to start. I suspect there will be many hospitals that are experiencing COVID-19-related hardships that will find it difficult to respond to audits in general, much less in a timely fashion.

And, pay attention to all of the waivers, flexibilities, coding, and billing guidelines that have been put into place during the PHE. You will need to refer to those as you appeal any identified overpayments. We are aware that hospitals have already experienced and successfully appealed coding denials that occurred in the early stages of the pandemic when coronavirus coding guidelines were still being developed and clarified. Visit the COVID-19 Resource Center on the AHDAM homepage to stay current.

Access the CMS FAQ here:

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Denise serves as the Senior Vice President at Denial Research Group – AppealMasters. Denise is also President of The Association for Healthcare Denial and Appeal Management. Denise is a Registered Respiratory Therapist, Registered Nurse, and holds a Master’s degree in Management Information Systems from the University of Illinois, Springfield.

Denise has over thirty years of experience in healthcare, including clinical management, education, compliance, and appeal writing. Denise has extensive experience as a Medical Appeals Expert and has personally managed hundreds of Medicare, Managed Medicare, and Commercial appeal cases and presented hundreds of cases at the Administrative Law Judge level.

Denise is a nationally known speaker and dynamic educator on Medicare and Commercial appeals processes, payer behaviors, standards of care, appeal template development, and building a road map to drive the payer to a decision in the provider’s favor. She has educated thousands of healthcare professionals around the country in successfully overturning medical care denials.