Medicare Audits Return in Full Force

After a hiatus during the height of the COVID-19 pandemic, Medicare audits have resumed in full force. Providers and suppliers should be prepared to respond to audits that were paused during the pandemic, the initiation of new audits, and audits relating to the various pandemic relief programs.

In early 2020, the Centers for Medicare and Medicaid Services (CMS) directed its contractors to pause audit activities as auditors were unable to work in the office and healthcare providers were reeling from the multiple impacts of the pandemic. CMS both paused in-progress audits and temporarily halted the initiation of new audits.

In late 2020, CMS authorized Medicare Administrative Contractors (MACs) to resume post-payment audits. Over the last year, CMS has authorized the resumption of nearly every type of audit and the initiation of new audits. As Medicare contractors process these directives and restart their audit activities, Medicare provides are seeing a wave of documentation requests, audit determinations, overpayment demands, and appeal decisions. Audits and claims appeals that have been dormant for a year or longer are suddenly active. New audits are being initiated for the first time in over year. And, in addition to audits by Medicare and other payors, providers must face compliance challenges and potential audits from pandemic relief programs, such as the Provider Relief Fund.

Meanwhile providers, many of whom are still dealing with the effects of the pandemic and the constantly shifting regulations of the government’s pandemic response, must reacquaint themselves with audit response procedures. It is important to remember that nearly all Medicare audits and claims denials come with significant appeal rights through five successive levels of appeals. Further, strict adherence to deadlines and documentation requirements can be just as important as the substance of the case when responding to a Medicare audit. Lastly, some types of audits, especially Targeted Probe and Educate (TPE) audits, carry the possibility that poor performance on the audit could lead not only to an overpayment demand, but also the revocation of the provider’s Medicare billing privileges.

Although providers are not required to retain an attorney to appeal their claims, the appeals process for Medicare can be extremely confusing and burdensome—there are also numerous legal and procedural arguments that can be argued by an experienced healthcare attorney.

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 and appealing audits and claim denials. If you or your healthcare entity has any questions pertaining to healthcare compliance, please contact an experienced healthcare attorney at 248-544-0888 or wapc@wachler.com.