COVID-19 Audits Still an Issue for Providers

Nearly 4 years after the beginning of the COVID-19 pandemic, healthcare providers continue to see payor audits and demands for repayment for services provided during the pandemic, primarily COVID-19 testing and vaccinations. While these services were an essential public function during the pandemic, constantly changing and often unclear rules and regulations governing the coverage of these services have created fertile ground for payors to allege after-the-fact that provider were not entitled to payment.

The issues asserted by payors tend to be systemic; that is, related to the process used by the provider rather than issues related to any unique characteristics of any specific claim. Therefore, these allegations often lead to demands that the provider pay back a significant portion of reimbursements for their COVID-19 services, often in the hundreds of thousands or millions of dollars.

COVID-19 audits tend to focus on a few common issues. Payors may audit providers based on the requirement for an “individualized clinical assessment,” including whether the ordering provider was authorized, whether the order for testing was within the scope of state law, whether the assessment was conducted by telemedicine or by a questionnaire, whether the ordering provider used a standing order, and what rules apply where a state does not or did not require an order for COVID-19 testing. The use of standing orders has become a particular point of contention, especially in cases where the practitioner who issued the standing order did not personally examine patients, was located offsite, or was under contract with and receiving reimbursement from the entity billing for the services.

Payors may audit the basis for COVID testing. Federal law generally required insurers to cover testing where an individual has symptoms of COVID-19 or a known, suspected, or potential exposure to the virus. Testing for return to work/school or for general screening purposes were generally not required to be covered, although insurers may choose to cover it. Testing for travel has generally become a contentious issue, depending on the circumstances.

Payors may also audit the various codes for specimen collection and/or travel allowances, including codes G2023 and G2024. These codes were introduced specifically for specimen collection for COVID-19. Early in the pandemic, their requirements were not well understood, so labs billed these codes often and insurers paid. However, as the requirements of these codes have become more well understood, insurers have begun to assert that labs frequently billed them when they were not appropriate.

For over 35 years, Wachler & Associates has represented healthcare providers and suppliers nationwide in a variety of health law matters, and our attorneys can assist providers and suppliers in understanding new developments in healthcare law and regulation. If you or your healthcare entity has any questions pertaining to audits for COVID-19 services or to healthcare compliance, please contact an experienced healthcare attorney at 248-544-0888 or wapc@wachler.com.