Blog by: Stacy Baker, OTR/L, RAC-CT, CHC, Proactive Medical Review

Following a year of little to no medical review and extensive government spending, most experts forecast reimbursement compliance audits ramping up in 2021. Multiple areas are ripe for potential scrutiny, including, but not limited to PDPM coding and supportive documentation, the proper use of SNF waivers, and appropriate access to and accounting for Provider Relief Funds. Get the facts and ensure readiness with these insights into the current audit environment and the medical review entities that may rain on providers in the months ahead. CMS suspended audits between March 30 and August 3 of 2020 in order to reduce provider strain during the COVID-19 pandemic. This year, however, audits are resuming in full swing.

  • Under the new Biden administration, many industry leaders and healthcare attorneys predict an uptick in audits and healthcare prosecutions with “both government initiated litigation and qui tam suits…set for continued growth in 2021” according to Georgia Ravitz et. al (i) With Xavier Becerra, a former prosecutor, appointed secretary of HHS, the government is poised to advance fraud prevention efforts.
  • False Claims Act (FCA) recoveries in FY2020 were $2.2 billion, down from $3.1 billion in 2019 and lower than any year since 2008 at a time when spending has escalated throughout the pandemic. Healthcare made up 85% of FCA recoveries in 2020 and that trend is likely to continue through both standard channels and a focus on new risk areas such as telehealth billing fraud. ii
  • Recovery Audit Contractors are now authorized to review for Medical Necessity and Documentation Requirements specific to the Patient Driven Payment Model (PDPM), and the OIG has added new focus to the Work Plan to identify program integrity risks associated with Medicare telehealth services during the pandemic.

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About Proactive Medical Review
HTS partners with Proactive Medical Review, a third party company who specializes in ensuring compliance with regulatory standards and promoting measurable care excellence. The team includes SNF experienced nurse, MDS, Health Facility Administrator, therapist and reimbursement specialists with experience serving in multi-site contract therapy operations, as corporate directors of quality, clinical program specialists, and Compliance Officers. Proactive is uniquely positioned to assist in managing the many changes and challenges facing providers partnered with HTS. Learn more about our commitment to compliance here.

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