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By Wayne van Halem, President, The van Halem Group

One of the biggest uncertainties of moving into a post-pandemic world is how CMS will decide to audit claims submitted during the public health emergency. There were a number of “waivers” and “flexibilities” that CMS put into place to try to get equipment to patients quickly and safely, and inevitably, a few bad actors will try to take advantage of the situation. That, coupled with CMS ceasing audit activity for a period of time, lends itself to potential compliance concerns.

We are already seeing Unified Program Integrity Contractors (UPICs) auditing pandemic claims for respiratory equipment with CR modifiers and identifying overpayments, so that is the likely tool in the CMS arsenal that they will utilize to perform these audits.  Unfortunately for suppliers, if the UPIC identifies an overpayment, it also implicates the six-year lookback rule where suppliers need to do their own self-assessment and voluntarily report overpayments on all claims submitted during the previous six years.

Obviously, the potential impact and burden on suppliers is significant and to date, CMS has not issued clear guidance on what parameters are being set for these types of reviews. What is also unclear is how CMS will handle claims for equipment set up during the pandemic, which also could lend itself to issues for suppliers whose patients may not qualify under normal circumstances. 

Amongst all the uncertainties, one thing that has been made clear by CMS is that they do intend to audit pandemic claims and as previously noted, already are. An understanding of the audit climate will be integral to avoiding ongoing issues and overpayments. As we help clients navigate through these types of issues, we gain an understanding of what CMS actions are and how to mitigate the risk as much as possible, from both a legal and compliance point of view. Suppliers will need the knowledge and understanding to prepare themselves for the inevitable audit requests on pandemic claims as well as an assessment of the parameters that CMS is using and what additional initiatives that CMS may implement in the future.

Please join me and Denise Leard at Heartland Conference where we will discuss current audit initiatives and documentation pitfalls that should be avoided. Learn more and register at www.vgmheartland.com.