Ending of the Public Health Emergency: What to Expect, What to Change, and What to Do

As the Public Health Emergency ends on May 11, 2023, billing compliance teams are faced with another “new normal” and must be prepared.

Getting used to a new way of working is just one of the many facets of the change that is to come. The one change most heavily weighing on compliance teams is the influx of external audits going back years. Payers – both commercial and government – will be digging into past claims, clawing back on payments, and asking for further documentation.

Let’s examine what’s changing, and more importantly, how to begin preparing for those changes.

Looming Changes

The powers that be have re-examined many of the waivers and flexibilities that came with COVID-19, and have altered many of the conveniences you’ve become accustomed to.

Here is some of what you can expect to stop starting May 11:

Stark Law waivers will end as CMS will no longer permit referrals and related claims submissions
Hospitals will no longer be able to screen patients at offsite locations – Emergency Medical Treatment and Active Labor Act (EMTALA) waivers are ending
The flexibility of the Social Security Act, where CMS temporarily waived the requirement for a three-day prior hospitalization for coverage of a skilled nursing facility (SNF) stay will end
CMS create hotlines for physicians, practitioners, and Part A certified providers and suppliers who created isolation facilities to enroll and receive temporary Medicare billing privileges will be shut down
During the PHE, practitioners could easily cancel their opt-out status early and enroll in Medicare to provide care to more patients. When the PHE ends, so will these leniencies.

NOTE: These are nowhere near all the changes, so be sure to check the CMS website for further information on what will change and what remains status quo.

What’s Going to Happen

Payers will begin with aggressive clawbacks going back years, and you can expect an uptick in DRG downgrades. They will also be asking for additional documentation focusing on COVID-related charges. Customers can do several things to best prepare, including bolstering their CDI Teams and resources, defining or updating their ADR workflows, and using advanced analytics to find outliers proactively.

Here are some other things you can expect:

Programs may not submit Medicaid claims using the modifier code CR (Catastrophe/Disaster related)
Shift in Payer Mix from Medicare to Commercial requestors
Pre-emptive monitoring and auditing of telehealth services, site of services, laboratory services, and other billing practices will be heavily scrutinized

What to do Next

Fret not. There is action you can take to start preparing your organization for the new way of working in addition to the deluge of demand letters coming your way.

Work with your operations leaders to determine which flexibilities your organization took advantage of during the PHE and review guidance by CMS to determine how they’ve changed; then, develop a roadmap on how these changes will be phased out.
Leverage federal agency fact sheets and reassess billing compliance ASAP to prepare for the end of the PHE
To endure continuity of patient care, you should reevaluate your service delivery platforms and business models, especially as it concerns telehealth
Develop an ADR (Additional Documentation Requests) program, if you have not already
Begin getting feedback from the revenue cycle concerning internal controls and monitoring regarding waiver-centric billing
Conduct a HIPAA assessment in your organization, especially as it pertains to telehealth

Here are some helpful links to get you started on your journey:

If you’re still bogged down by spreadsheets and manual processes when handling external audits, consider adding software that will help streamline your responses, improve collaboration between case management, revenue integrity, coding, CDI, and physicians, and can easily help you report your results with analytics. Considering what lies ahead, it’s the ideal time.