Audits of COVID-19 Related Services Continue for Primary Care Providers and Labs

By: Jennifer Colagiovanni, Wachler & Associates, P.C.
2/27/2024

Nearly 4 years after the COVID-19 pandemic began, healthcare providers continue to see payor audits and demands for repayment of services provided during the pandemic, primarily related to COVID-19 testing and lab services, as well as for evaluation and management (E/M) office and telehealth visits. Despite the fact that these services served a critical public health function during the pandemic, constantly changing and often unclear guidelines governing coverage and documentation of these services have created fertile ground for payors to allege after-the-fact that providers were not entitled to payment.

The audit issues asserted by payors tend to relate to the process used by the provider rather than issues related to any unique characteristics of a specific claim. Therefore, these allegations often lead to demands that the provider pay back a significant portion of reimbursements for the COVID-19 services they provided over a particular time period, often in the range of hundreds of thousands or even millions of dollars.

Audits of COVID-19 services have centered around several common issues:

E/M Visits: E/M services were provided to assess symptomatic patients and those with known exposures, all against the backdrop of changing public health guidance and fluctuating positivity rates in local communities. Depending on the practice and the COVID-19 restrictions in place at a given time, these visits may have been provided in-person or by telehealth. The pandemic led to the rapid expansion of telehealth services through government waivers and flexibilities in an effort to enhance access to care for patients. By way of example, the Government Accountability Office estimated that the use of telehealth services in Medicare rose tenfold–from 5 million visits between April and December 2019 to 53 million telehealth visits during the same period in 2020. The expansion of telehealth was similarly seen in Medicaid. The result: many patients (and providers) found themselves using telehealth for the first time. This, coupled with serious staffing strains on healthcare providers, major changes to office/outpatient E/M guidelines, and changing COVID-related guidance created challenges that are now being subjected to retrospective audit scrutiny. The added challenge is that audit reviews focused on technical compliance may neglect to account for the real-world uncertainty and undercurrent of ever-changing guidance that were a reality of the pandemic for healthcare providers.

COVID-19 Testing: Labs continue to face payor audits related to COVID testing. The Office of Inspector General (OIG) announced a series of audits of Medicare Part B laboratory services that will include a focus on “aberrant billing of COVID-19 testing during the pandemic.” Likewise, labs have also seen commerical payors focused on COVID testing. Audit reviews may be based on the requirement for an “individualized clinical assessment,” including whether the ordering provider was authorized, whether the order for testing was within the scope of state law, or whether the assessment was conducted by telemedicine or by a questionnaire. Whether the ordering provider used a standing order and what rules apply where a state does not or did not require an order for COVID-19 testing also serve as potential audit issues.

Payor audits have also focused on the underlying reason for COVID testing. Federal law generally required insurers to cover testing where an individual has symptoms of COVID-19 or a known, suspected, or potential exposure to the virus, whereas testing for return to work/school or for general screening purposes was generally not required to be covered, though some insurers chose to. Similarly, testing for travel is a potential area of focus. The “gray area” that surrounded patients’ stated reason for testing has resulted in an area ripe for audit scrutiny.

Payors may also audit the various codes used for specimen collection and/or travel allowances, including codes G2023 and G2024, which were introduced specifically for specimen collection for COVID-19. Early in the pandemic, the requirements for these codes were not well understood, so labs that billed these codes and received reimbursement may face audit vulnerabilities.

With the frenetic energy of the pandemic in the rear-view mirror, retrospective audit reviews may not adequately account for the uncertain prognosis the virus presented, the ongoing staffing and operational challenges providers faced, or the public health function primary care and labs played in combating the virus. Health care providers are well-advised to take audit reviews of COVID-19 services seriously and contact an experienced healthcare lawyer for assistance in navigating the audit and appeals process.