By KAITLIN A. NUCCI, ESQ.
Wachler & Associates, P.C
Regardless of the fact that the United States is still in the midst of a public health emergency battling the spread of COVID-19, the Center for Program Integrity encouraged the Centers for Medicare and Medicaid Services to resume both Recovery Audit Contractor (RAC) and Medicare Administrative Contractor (MAC) audits. For now, these audits will focus on claims submitted prior to March 1, 2020. CMS has not yet stated when they will be auditing claims submitted after March 1, 2020 and through the duration of the current public health crisis, but professionals in the field expect these audits to begin in the coming months. Providers are encouraged by CMS to discuss any COVID-19 related hardships that may affect audit response times.
While it is not clear when audits for claims submitted after March 1, 2020 will begin, providers should be prepared for post-payment reviews, particularly with regards to COVID-19 claim submissions. In fact, CMS has announced a new requirement to obtain reimbursement for COVID-19 patients. Beginning Sept. 1, 2020, a provider will receive a 20 percent Medicare reimbursement add-on payment for a COVID-19 patient only if the provider documents a positive test in the patient’s chart. This new guidance applies only to Inpatient Prospective Payment Systems (IPPS), Long-Term Care Hospitals (LCTHs), and Inpatient Rehabilitation Facilities (IRFs). This 20 perecent add-on payment will be automatically added to the claim payment but will be enforced through post-payment audits to come in the future. Thus, this bonus will be recouped if a provider cannot provide a positive COVID-19 test in the patient’s chart. Many providers are concerned with this requirement, and are encouraging CMS to allow diagnosis based upon a provider’s clinical judgment alone while still being allowed to receive the 20 percent add-on payment. However, CMS has made it clear that this positive test must be a positive viral test consistent with CDC guidelines, so many types of state and local COVID-19 tests that providers have been using will no longer be sufficient for this 20 percent add-on payment from Medicare.
Providers should also be prepared for future audits regarding Remote Patient Monitoring (RPM) codes. Providers have been permitted since April 30, 2020 to report RPM to Medicare for periods of time between two and 16 days, so long as the public health emergency is still ongoing. To be eligible for payment of these codes, providers must be able to demonstrate medical necessity in the patient’s record, and a failure to do so will result in denials of payment. Providers should ensure that they are continuing to document the medical necessity of these services in anticipation of audits to come.
Providers should also be prepared for audits conducted by private payors, as these insurance companies have resumed auditing activities of claims, which even include COVID-19 related claims. Specifically, Wachler & Associates is aware of private payors initiating audits of laboratories. All laboratories doing any type of COVID-19 test should be on notice of potential audits coming.
These private payors are requesting large volumes of materials in addition to requesting information regarding the actual COVID-19 tests: copies of CLIA Certificates, CMS-116 Applications, lists of testing equipment, invoices, lists of reference labs, shipment logs, credential for all laboratory staff, lists of daily test volume performed onsite, hours of operation, specimen processing policies, proficiency test reports, patient service center permits, and emergency use authorizations. These requests go above and beyond the standard materials requested in an audit prior to the COVID-19 crisis. Any laboratory that performs COVID-19 testing should be prepared for a potential audit and the strenuous document production that may come with it.
For additional information or assistance regarding how your facility can transition into the reopening phase while following Governor Whitmer’s guidelines, or any other health professional issue, contact Kaitlin A. Nucci, Esq., at Wachler & Associates at (248) 544-0888.