Restarting Program Integrity Efforts During and After a Pandemic

May 15, 2020 HMS

In January, there was awareness of the coronavirus (COVID-19), but its potential impact on the U.S. was not yet evident. By March, of course, that had changed and the U.S. was forced to quickly prepare, mitigate and respond to a pandemic of which little was known. Since then, it has become clear that the COVID-19 pandemic requires healthcare access for all who need it and capacity to properly care for those affected from this contagious virus.

At the onset, healthcare stakeholders, including state and federal policymakers as well as health insurers, took immediate action. Hoping for the best – but preparing for the worst – rules, regulations and programmatic changes were made to increase access and build capacity, including alleviating burdens or administrative requirements for hospitals and other providers.

Many of the changes involved program integrity (PI) and alleviation of fraud, waste and abuse (FWA). The Centers for Medicare and Medicaid Services (CMS), several state insurance departments and some insurers took action to suspend some or even all PI and FWA activities. For example, CMS waived the Social Security Act requirements for skilled nursing facility (SNF) stays and relaxed the requirements around appeals.  Also, several states suspended in-network hospital and emergency services reviews during the public health emergency period.

Thankfully, initial projections on those infected have not yet come to fruition and, outside of key metropolitan areas, most providers have not begun to see patient volume increases.  Currently many areas of the country are experiencing reduced rates of infection and testing capacity growth, lending to state and national re-opening planning.

As this re-opening progresses, we urge state and federal regulators, policymakers and insurers to thoughtfully restart and enhance oversight efforts to address PI and FWA.  During this crisis, there may be an increase in inaccurate coding and billing due to ongoing stress on the staff and systems, and confusion around new ICD-10, CPT and HCPCS codes. Increased FWA vulnerability due to the relaxation of certain rules, regulations and other requirements may also occur.

At the same time, our economy is reeling from this crisis with high and rising levels of unemployment and greater dependence on publicly administered healthcare programs while tax revenues supporting those programs dwindle. PI and FWA deterrence can help offset some of those dynamics and simultaneously ensure appropriate, high quality care.

There are few, if any, easy decisions to be made about re-opening and planning for a new normal following COVID-19, but restarting and enhancing PI and FWA healthcare efforts may be one of the most effective. For those that changed, limited or stopped FWA activities, it is critical to ensure a coordinated thoughtful restart. We recommend that states and payers look closely at these early decisions and resume normal FWA activities in areas with low numbers of COVID-19 patients and on providers who have been minimally impacted by the pandemic.

Thirty-six governors (and the District of Columbia) issued moratoriums on elective procedures. If elective procedures are resuming, not only consider that as a strong indicator for restarting PI activities, but also think of it as a necessary trigger given that healthcare consumption will vigorously resume due to pent up demand.

For heavily affected areas and/or providers, we recommend:

  • An incremental resumption of payment integrity, such as gradually increasing over a few months the number of medical record requests
  • Conducting reviews on all documentation already received, but holding findings, while retaining full lookback rights and developing a plan for catch-up
    • Maintaining and possibly increasing automated reviews
    • Affording up to a 30-day buffer for medical record requests, appeals and technical denials
    • Facilitating electronic transmission of medical records and documentation
    • Notifying providers prior to sending a technical denial letter
    • Conducting targeted outreach and education

Finally, we highly recommend a special focus on reviews associated with COVID-19 flexibilities and impacts. For example, HMS anticipates an increase in the billing of inpatient level of care during this period when requirements are relaxed or waived. Place of Service reviews can help identify overutilization of services and inaccurate billing of inpatient services.

New laboratory testing CPT and HCPCS codes have been created. As with the release of any new code, there will be confusion on how to bill and the anticipated volume of claims will result in large overpayments if billed in error, warranting a special review.

CMS relaxed telehealth benefit requirements to enable patients to receive necessary services while reducing risk of COVID-19 exposure. These changes while temporary may in fact prove to be more permanent, opening up telehealth more generally and longer-term. This is an area that deserves special attention to ensure FWA is not rampant given the relative newness.

Many entities have requested waivers of all pharmacy audits and authorizations to be suspended during the declared emergency period. While these waivers are necessary to lessen the burden on pharmacists during this period and ensure patient access, providers must still follow policy and billing requirements.  HMS recommends performing retrospective reviews of pharmacy claims billed during this period to validate claims were billed accurately.


For more tips on maintaining program integrity during the COVID-19 pandemic, download our full Restarting Program Integrity guide.

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