The Centers for Medicare & Medicaid Services (CMS) resumed Recovery Audit Contractor (RAC) and Medicare Administrative Contractor (MAC) medical review audits in August.
Here’s what you need to know and how to prepare your skilled nursing facility in the event of an audit.
RACs and MACs are back
The ongoing COVID-19 public health emergency (PHE) brought considerable changes to healthcare facilities, including a temporary halt to most CMS audits on March 30, 2020. The suspension included prepayment and post-payment medical reviews conducted by MACs and RACs.
In July, CMS announced that it would be resuming medical review activities in August regardless of the status of the PHE. Audit activity ramped back up on August 17, prioritizing post-payment reviews of COVID claims submitted prior to March 1, 2020.
While CMS has not yet announced when the audits on claims submitted after March 1 will begin, they will likely commence in the coming months.
What you need to know
CMS has indicated that audits will be conducted in accordance with existing statutory and regulatory provisions, including related billing and coding requirements. However, any waivers or flexibilities that were allowed for any date of service under review will be applied in the audit.
Keep in mind that the rules changed rapidly at the onset of the PHE, which may increase the chances of audit errors as well as misapplication of rules and regulations.
If auditors are unable to make a determination on prepayment or post-payment claims review based on the information that’s been provided, they will issue an additional documentation request (ADR) to solicit supporting documentation.
While RAC and MAC audits historically have been done in person, CMS has expanded desk reviews during the pandemic. Although a remote audit may potentially be less burdensome on your organization, it will still be crucial to be organized and prepared.
Tips for audit response
CMS recognizes that many skilled nursing facilities have limited staffing and resources to respond to audits during this time. If your facility is selected for medical review, there are several actions you can take to facilitate the process.
- Identify someone to manage the ADR and denial process
- Promptly respond to every overpayment and audit letter (ADR)
- Contact your auditor to discuss any COVID-19 related hardships you may be experiencing that could impact audit response timeliness
- Avoid returning any overpayment before confirming and accepting the audit findings
- Only send the specific information in the ADR to expedite the process
- Make sure all documentation is legible and supports MDS coding and the UB-04
Boost audit success
Audits are disruptive even during the best of times. It’s more critical than ever to have an efficient and effective process in place to not only respond to an audit in a timely manner, but to also help you avoid one in the first place.
ABILITY CAREWATCH and ABILITY UBWATCH can help you get ahead of an audit request and potentially minimize the risk of an audit by ensuring accuracy between the MDS and UB-04. Data analytics and real-time reports give you access to:
- Medicare roster
- RUG 66 Watch page
- Built-in Triple Check
- Quality pages
- And more!
There’s no time to waste! Get a first-hand view of how to use these applications to boost your audit response by requesting a demo today.
“Coronavirus waivers & flexibilities,” CMS, accessed October 9, 2020, https://www.cms.gov/about-cms/emergency-preparedness-response-operations/current-emergencies/coronavirus-waivers.
“MACs Resume Medical Review on a Post-Payment Basis,” MLN Connect eNews, CMS, August 6, 2020, https://www.cms.gov/outreach-and-educationoutreachffsprovpartprogprovider-partnership-email-archive/2020-08-06-mlnc#_Toc47449031.
“CMS Announces Resumption of Routine Inspections of All Provider and Suppliers, Issues Updated Enforcement Guidance to States, and Posts Toolkit to Assist Nursing Homes,” CMS, August 17, 2020, https://www.cms.gov/newsroom/press-releases/cms-announces-resumption-routine-inspections-all-provider-and-suppliers-issues-updated-enforcement.
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