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Will the Biden Administration Change Your Compliance Risk?

April 23, 2021
Compliance By Kay Hashagen, Senior Consultant

The year 2021 brings a new President and a new Administration. As evidenced by his $1.9 trillion COVID-19 Relief Bill, passed in March 2021, President Biden’s plan includes expanding government-run health insurance while placing increased emphasis on quality oversight.

 

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To offer more to the constituents under Medicare, it will be essential to obtain savings wherever possible. With this new Administration, you should be asking yourself: “Will the compliance audit focus of Federally funded payments shift?” When speculating the answer to this question, providers should consider the following:

  • Audits: Recovery Audit Contractor (RAC) audits are one type of audit to watch. The government created the RAC program as part of the Medicare Prescription Drug, Improvement, and Modernization Act of 2003. The RACs are responsible for identifying Medicare overpayments and underpayments while highlighting common billing errors, trends, and other Medicare payment issues. Keep in mind RACs are paid a contingency for identified errors. As such, RACs may yield high value and low risk for the Centers for Medicare and Medicaid (CMS) in combating fraud, waste, and abuse. The audit data maintained and created by RACs provide useful data to CMS in making regulation changes in the future. It is expected that RAC audits will increase under the Biden administration.
  • Telehealth: Telehealth related to the COVID-19 outbreak and requirements is another focus area to watch. Due to the increased use of telehealth to prevent physical contact but allow visits to occur, the expansion of telehealth coding and requirements was significant in 2020 into 2021. With an increase in use, one can expect an increase in errors, inappropriate coding and documentation. It is expected that a review of telehealth billing will be a focus under this new administration.

Is Your Facility Prepared to Respond?

What can your facility do to prepare to respond to an audit request timely? Have a process in place to respond by a designated team or person. Being prepared and having prior knowledge of the documentation required to respond to an audit are the keys to any successful audit. The designated response team must know the rules and regulations, outlined by CMS, to provide the necessary documentation to defend the audit. Facilities' typical response to audits for non-telehealth delivered services will not be so “typical” if telehealth services were provided. Staff must identify the “additional” key documents to submit in response to an audit where telehealth was provided, or an immediate denial may occur. It is critical when there are new regulations, as in the case of telehealth, to provide additional staff training when responding to audits going forward.

How Can LW Consulting, Inc. Help?

LW Consulting, Inc. (LWCI) can assist facilities in identifying new or updating current audit response processes. Having an internal monitoring process to quickly identify if the facility has come under an audit is critical.

Facilities may also be unsure if the Blanket Waiver, Telehealth Consent, or the DR Modifier were applied compliantly and may benefit from an external audit. LWCI conducts external, objective audits for facilities to assess compliance while identifying missed opportunities to capture complex patient care. Conducting a regular review of documentation and coding supports a compliance plan’s purpose, to identify non-compliance in supporting claims. Lack of awareness of a coding requirement is not acceptable to payers.

 

LW Consulting, Inc. can assist you with audit reviews and training. For more information, contact Kay Hashagen, Senior Consultant, at 410-777-5999 or email khashagen@lw-consult.com.

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