The 5 Steps To Prepare For Your Uninsured Program Audit
Insurance Discovery Is The Key To Your Due Diligence
All healthcare service providers were challenged to partner with the government to diagnosis and treat patients who were impacted by covid. Many providers began offering Covid-19 testing for both insured and non-insured patients as per the government mandates - no patient was to be left behind due to their medical coverage status. In haste, many claims didn’t get thorough vetting and now re-payments are a very real possibility.
Through the COVID-19 Claims Reimbursement to Health Care Providers and Facilities for Testing, Treatment, and Vaccine Administration for the Uninsured Program, $18.8 Billion were paid to providers. The program ended in March 22 for testing and treatment and April 5 for vaccinations. All claims sent after that time will not be processed and will be denied. Funds received by providers under the requirements of the Uninsured Program do not need to be repaid if they were used appropriately.
The issue now is regarding claims that were not verified thoroughly, and these reimbursements are subject to scrutiny under compliance, reporting and auditing requirements. It is most important to know that claims found to be out of compliance during an audit, must be repaid to HRSA. In addition to potentially facing substantial re-payments, providers will be subjected to penalties and even legal actions.
While filing a claim against a payer is standard practice, it is more difficult when providers don’t know which payor is correct. The due diligence requirements as defined by HRSA stated that a provider would ensure that a thorough process was followed to properly identify the patient and confirm they had no active coverage during the period they were serviced to be reimbursed by the Uninsured Patient Program. How was that accomplished? Was it thorough enough?
What HRSA defines as thorough is unclear. Whether providers ran 2, 4 or 8 payors may or may not be viewed as enough or thorough. On average, running 8 payors including Medicare, Medicaid and the top 6 private payors will capture 90% of regional payor coverage to determine eligibility verification. The absolute best outcome is accurately matching eligibility at the highest possible rate initially instead of now needing to predict how much due diligence is enough. The focus of recent audits appears to be on identifying the patient identification used in the claims.
While some providers had a manageable amount of patients to service, others felt the tsunami wave of COVID crashing in daily and were required to utilize all resources to process claims. HRSA audits will have little to no impact on providers who can clearly document an audit trail by patient or in batches by using intelligent verification that shows verified patient demographic information and matching insurance eligibility. Anything less and repayments may be forthcoming. The good news is that it isn’t too late to audit yourself and remedy any issues ahead of a HRSA audit to avoid penalties.
“We found that 68% of patients who claimed to be uninsured, or simply were not required to provide that information during services, actually had coverage,” said Christina Cuartas, Vice President, Client Success, tevixMD. “Getting verification right up front is now proving to be even more valuable due to government audits. We achieved error-free submissions for thousands of patients and achieved a 100% hit rate on a “path to payment.”
While there are still many questions regarding Uninsured Program reporting and audits, it’s clear that proactive audit preparation will identify any financial risk, expedite any HRSA audit and help deliver the most positive outcome. Some providers are conducting self-audits and returning funds to HRSA for claims found to have insurance to avoid further exposure.
If you find HRSA claims that should be repaid, avoiding penalties is a good thing but, uncompensated healthcare services should not an option either. The process of resubmitting denied Uninsured Program claims to payors should begin immediately in order to reclaim this unexpected lost revenue. It will be important to keep track of payor deadlines for submitting these COVID related claims, so time is of the essence.
Disclaimer: tevixMD is not providing legal advice, we are only providing information on how our solution can help you be compliant with HRSA.