In a previous post, we announced that CMS would be resuming program integrity audits in August. This recent article explained some additional details of their “short-lived hiatus.”
Despite the continuing public health emergency (PHE), CMS did resume on August 3rd pre-payment and post-payment audits in its quest for integrity of the Medicare program. Providers may be targeted for review based on high utilization of particular billing codes or some other “abnormality” found during a review of CMS’s analytics. It’s important to understand that during the PHE when audits were suspended, CMS was still busily focused on data mining its claims for aberrations. One area in the cross-hairs is telehealth (TH) claims. Medicare is specifically looking for fraudulent TH charges, including “providers who bill for more visits per day than are humanly possible.”
Keep in mind, as we discussed in this FAQ document, the requirements for TH visits (documented consent, proper billing codes) and that some Medicare services require audio/video and not just telephonic services. The author of this article explains that given all the changes that occurred early in the PHE, claims paid during the first 60 days may be subject to different rules and may be more likely to contain errors, and be ripe for auditing.
What should you do if you’re selected for an audit? First, don’t panic 😊 but do be timely in your response. If responding to a documentation request would create a hardship for your practice (e.g., reduced staffing), discuss this with the auditor. Also, CMS will be taking into consideration any waivers or flexibilities offered during the PHE; we suggest providers go back through email notifications and CMS guidance to be clear on the internal changes you made as a result of those communications. Finally, as the article says, avoid prematurely returning any overpayments until you confirm the audit findings.
Remember that targeted probe-and-educate (TPE) reviews are meant to help you improve your documentation, coding and billing, so try to keep an open mind that TPE reviews could turn out to be a good exercise. (Like 2020 couldn’t get any worse.)