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New COVID-19 Related Audit Considerations

By March 12, 2021March 23rd, 2021Claims, COVID19, Vaccines

New COVID-19 Related Audit Considerations

In addition to all of the other usual audit concerns, Plan Sponsors should also be prepared for CMS to scrutinize all things COVID-19 related. As BluePeak has previously shared, CMS focused on COVID-19 related care and delivery in its 2020 audits.  Here are some important areas to consider:


CMS will likely audit the accuracy of the adjudication of both Part C and Part D COVID-19 claims. BluePeak recommends routinely pulling a report of claims that were processed during the pandemic and analyzing what was paid, denied and the cost-sharing applied to ensure the claims processed align with CMS requirements and waivers.

Keep in mind that The Families First Coronavirus Response Act (FFCRA) waives cost sharing, both coinsurance and deductible amounts, for Medicare Advantage enrollees receiving COVID-19 tests and testing-related services. In addition, The Coronavirus Aid, Relief, and Economic Security Act (the CARES Act) amended the FFCRA to provide a broader range of diagnostic items and services that Medicare Advantage Plans must cover without any cost sharing requirements or prior authorization or other medical management requirements.  During an audit, CMS will be reviewing claims to ensure these waivers were correctly and consistently applied.


Telehealth visits have increased exponentially during the pandemic, as these visits enabled delivery of medical care while providing increased safety and convenience for providers and members.  From a risk assessment and compliance oversight perspective, the Plan Sponsor and all delegated entities processing claims must ensure they are reviewing and updating billing policies and claims edits.

  • 89 codes temporarily added for permissible reimbursement during pandemic (15 permitted to be audio only)
  • Five new codes added 4/30/20 – some with Medicare limitations
  • Three new codes added 10/14/2020
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