Medicare-enrolled providers should prepare for resumed CMS fee-for-service medical reviews and audits. On March 30, 2020, CMS suspended most reviews due to the COVID-19 pandemic. This included pre-payment reviews conducted by Medicare Administrative Contractors, reviews conducted by Recovery Audit Contractors (“RAC”), and the CMS Target Probe and Educate (“TPE”) program reviews. However, on August 3 2020, CMS announced that it would resume these reviews “regardless of the status of the public health emergency.” If the provider is selected for review and is experiencing hardships due to the pandemic, the provider may discuss audit response deadlines with the reviewing contractor.
A provider may be selected for audit based on high utilization of particular billing code or some other abnormality identified by CMS in its data analytics. If a provider is selected for a TPE review, the provider will typically receive notice by mail with a request for medical records associated with 20-40 previously submitted claims. The auditor will then work with the provider on any areas of identified non-compliance. If the auditor does not see improvement over three rounds of this, the provider will be referred to CMS for further review. Pre-payment and RAC audits consist of records requests and notification of any identified audit findings, but do not have the education component that TPE reviews have.
Government audits can be uncertain and intimidating, which is why it helps to have the assistance of counsel to navigate through the process. We have assisted many providers through this process and, if needed, helped them implement compliant billing practices after the review. If you have received a notice or if you would like more information about best practices, please contact us.