CMS To Begin Medicare Audits: What This Means For Providers

In order to ensure that hospitals, clinics, and other healthcare providers are not being overpaid for Medicare services, CMS usually conducts on-going audits. However, CMS suspended most fee-for-service claim audits and medical reviews by Medicare Administrative Contractors (MACs) on March 30th of this year due to the coronavirus pandemic. Suspension continued through most of the summer, but the agency resumed auditing providers’ Medicare claims on August 3rd. CMS stated this summer that the audits will continue “regardless of the status of the public health emergency.”

The Audits That Have Been Resumedhand holding a magnifying glass over paperwork

 CMS has resumed both prepayment and post-payment medical reviews conducted by:

  • The Medicare Administrative Contractors
  • The Supplemental Medical Review Contractors (SMRC)
  • The Recovery Audit Contractor (RAC)
  • Any contractors under the Targeted Probe and Educate (TPE) program

What This Means For Healthcare Organizations

As states began to reopen this summer, CMS made it clear that they did not expect to extend the enforcement discretion period for audits any longer. At this point, all organizations should be taking the appropriate steps to be prepared for an audit in case it happens, including notifying all staff involved. If an organization is selected for review and they have any hardships related to the pandemic, they can discuss them with their contractors.

doctors dressed head to toe with protective gear seeing an elderly man with a mask on.
CMS indicated that hospice care providers will most likely be selected for audits.

CMS noted that “auditors will be applying any waivers and flexibilities in place during the emergency period, otherwise all reviews will be conducted in accordance with statutory and regulatory provisions, as well as related billing and coding requirements.”

According to CMS, hospices are among the most utilized Medicare services. Because of this, CMS indicated that hospice care providers will most likely be selected for audits. When they are selected, they will have a chance to speak with their contractor about any hardships in replying related to the pandemic

Many hospice care providers are worried about getting through an audit during this difficult time, especially since being subject to one would redirect focus away from patients, families, and hospice caregivers. “Staff are already being pushed to the limits. We’re operating with constraints in terms of how we can access patients. We’re operating mostly virtually right now, which is cumbersome,” Peter Brunnick, president and CEO of Hospice & Palliative Care Charlotte Region told Hospice News. “To add the audit process, which would require getting staff in-house pulling records and sitting down with auditors, is counter to everything we’re doing now trying to be socially distant and practice safety.”

“We recognize that oversight, even in a pandemic, is important, and we have no patience or tolerance for fraud and abuse. On the other hand, asking a compliant provider to take time out of providing care to their population in the middle of a global pandemic is not the best idea,” said National Hospice & Palliative Care Organization President and CEO Edo Banach. “There is a lot of consternation out there about the possibility that individuals are going to be pulled out of the field into the office and sift through records at a time when really all hands are needed on deck.”

CMS claims that they are taking the pandemic into consideration while doing these audits, so that they will not interfere with healthcare providers providing care to those who really need it.

About The Author:
Cassandra Love

With over a decade of helpful content experience Cassandra has dedicated her career to making sure people have access to relevant, easy to understand, and valuable information. After realizing a huge knowledge gap Cassandra spent years researching and working with health insurance companies to create accessible guides and articles to walk anyone through every aspect of the insurance process.

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