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Analysis

Audits For COVID-Related Inpatient Stays are Here

By Alexandra Wilson Pecci  
   October 23, 2020

"We are already seeing the early COVID-19 cases being audited from commercial payers," said Dawn Crump, MA, SSBB, CHC, senior director of revenue cycle solutions for MRO Corp.

On August 3, CMS resumed Medicare fee-for-service audits which had been suspended since March 30 because of the COVID-19 public health emergency (PHE).

On the same day, several new topics were approved for recovery audit contractor (RAC) review, including total knee and total hip arthroplasty for medical necessity and documentation requirements.

HealthLeaders spoke via email with Dawn Crump, MA, SSBB, CHC, senior director of revenue cycle solutions for MRO Corp. to tell us about the implications for revenue cycle leaders.

HealthLeaders: Why are the RAC reviews for total knee and total hip arthroplasty particularly noteworthy?

Dawn Crump: These are high-dollar, high-volume procedures and if the documentation is not present in the submitted documentation it could be costly for hospitals.

HL: How did the spring and summer provide a reprieve from audits?

DC: There has been a reprieve for hospitals on the government audit and appeal side that has resulted in many locations furloughing staff in these areas to reduce the impact of COVID-19. However, many commercial and Medicaid audits still impacted providers during the PHE creating burden and impacting payments. We are already seeing the early COVID-19 cases being audited from commercial payers.

HL: We're a couple months in: How's it going?

DC: Our providers have had RAC audits begin again, but so far, they have not had any [for] total knee and total hip arthroplasty.

HL: What's the word/update with other payers?

DC: Overall, some larger payers followed suit with CMS and suspended their audits, but they resumed earlier this summer and are definitely looking at claims related to COVID-19 inpatient stays.

In addition, payers are starting to implement additional rules to require medical record documentation submission on certain claim types with high charges as a condition of payment.

HL: What do revenue cycle executives specifically need to know regarding this topic?

DC: Revenue cycle executives looking for a project to become more efficient when managing audits and denials should look at how medical record requests are managed within their business offices.

A centralized business office managing financial services for multiple hospitals can have millions of dollars in AR aging due to submission and follow up of attachments not to mention the time it takes for billers and collectors to respond to these requests.

Alexandra Wilson Pecci is an editor for HealthLeaders.


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