When Will We Begin Seeing Medical Review Audits Following the COVID-19 PHE?

While it is still unclear at this time when we will begin to see normal audit activity resume from traditional Medicare entities, some Managed Care companies have lifted their suspensions and may have resumed normal auditing practices as early as May 15, 2020. Humana released a memo on May 14, 2020 stating the following

“Given that health system capacity is opening up and procedures are increasing steadily, we will begin to resume some of the regular processes that we suspended on April 1, 2020, to support providers with the strain on the healthcare system posed by COVID-19 at the heart of the crisis…The first of these is for medical record requests for claim reviews, which we will resume effective May 15, 2020.

  1. Resuming pre-payment medical record claims review. As of May 15, Humana may begin to request medical records from your organization prior to issuing payment, consistent with our policy in place prior to the April 1 suspension.
  2. Resuming post-payment medical record claims review. Since April 1, Humana has not requested medical records in connection with our post-payment review process. Our post­ payment claims review team will now resume making requests for medical records as required, consistent with our policy in place prior to April 1.

Humana leaders will continue to monitor service volumes as well as the progression of the COVID-19 curve and recovery and will review our policies and procedures as necessary as this crisis evolves.”

Please be prepared to start seeing these requests again in the coming days and weeks and notify your Medical Review/Appeals department as soon as possible. It is highly possible that there will still be barriers to obtaining medical records timely and extensions may need to be requested. We are all in this together and are happy to assist in any way possible.

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