CMS Directs Auditors to Get Back to it on August 3; Prior Auth Programs Get the Greenlight Too

Published in Member Communities on July 09, 2020

The van Halem Group released a blog stating that beginning August 3, MACs, RACs and the SMRC will 'flip the switch' and reinstate their audit functions. CMS notes that the waivers and flexibilities in place at the time of the dates of service of any claims potentially selected for review will also be applied.

Below is the full blog post:

In the most recently published Coronavirus Disease 2019 (COVID-19) Provider Burden Relief Frequently Asked Questions (FAQs) a question related to the suspension of medical review leads the list of FAQs. The question, in it's entirety reads as follows, "Is CMS suspending most Medicare Fee-For-Service (FFS) medical review during the Public Health Emergency (PHE) for the COVID-19 pandemic?"

The short answer, not anymore. In part, the CMS states that, "As states reopen, and given the importance of medical review activities to CMS’ program integrity efforts, CMS expects to discontinue exercising enforcement discretion beginning on August 3, 2020, regardless of the status of the public health emergency."

Beginning August 3, MACs, RACs and the SMRC will 'flip the switch' and reinstate their audit functions. CMS notes that the waivers and flexibilities in place at the time of the dates of service of any claims potentially selected for review will also be applied.

So yes, claims billed to Medicare during the PHE are also subject to audit.

The document also indicates flexibilities in responding, specifically, that if a provider is selected for medical review and is experiencing a COVID-19 related hardship that may affect audit response timeliness that they should discuss this with the contractor.

Claims with an initial date of service on or after August 3, 2020 will also for Power Mobility Devices and Pressure Reducing Support Surfaces that require prior authorization as a condition of payment, must be associated with an affirmative prior authorization decision to be eligible for payment.

Lastly, the prior authorization for certain lower limb prosthetics (LLP) will be required with dates of service on or after September 1, 2020, in California, Michigan, Pennsylvania, and Texas. On December 1, 2020, prior authorization for these codes will be required in all of the remaining states and territories. LLP codes that will require prior authorization as a condition of payment include HCPCS L5856, L5857, L5858, L5973, L5980, and L5987.

Click here to view the original post.


comments powered by Disqus

From Our Experts

VGM Wound Care and Permobil Discuss the Importance of Seated Posture thumbnail VGM Wound Care and Permobil Discuss the Importance of Seated Posture In this episode of industry matters Director of Wound Care, Heather Trumm, talks with Stacey Mullis, Director of Clinical Marketing at Permobil, where “Every person has the right to have his or her disability compensated as far as possible by aids with the same technical standard as those we all use in our daily lives.” Heather and Stacy are going to dive right into dive into something that is often overlooked, and that is seated posture in wound care. Key Marketing Priorities for HME Providers in 2021 thumbnail Key Marketing Priorities for HME Providers in 2021 Now that 2020 is officially in the rearview mirror, it's time to get strategic in 2021 with resources, priorities, and investments. From a marketing perspective, healthcare delivery models have undoubtedly changed. Lindy Tentinger discusses key marketing priorities that can help your company achieve its business goals and set it up for continued success. CRT Telehealth Update from NCART thumbnail CRT Telehealth Update from NCART NCART and the CRT Remote Services Consortium announced their continued efforts to secure a permanent telehealth option for people with disabilities who require complex rehab technology (CRT). Navigating Lead Generation Safely thumbnail Navigating Lead Generation Safely Lead-generating companies are prevalent in the industry and are legal, but it is essential that providers understand exactly what service they will provide and how they will do it. Member Spotlight: Leo Levine, Owner, Merrick Surgical Supplies & Home Care thumbnail Member Spotlight: Leo Levine, Owner, Merrick Surgical Supplies & Home Care Meet Leo Levine, owner of Merrick Surgical Supplies & Home Care! A VGM member since 2019, Leo has taken what he's learned during his time as a member and used it to help him grow his business. Is Medicare Advantage Too Good to be True? thumbnail Is Medicare Advantage Too Good to be True? In a recent HME News article, Dan Fedor provides three important items for CRT providers to know about Medicare Advantage plans. What Healthcare at Home Means for DMEPOS thumbnail What Healthcare at Home Means for DMEPOS This year has been one of the most taxing years in history for everyone. We have all been keeping safe at home, which has caused the need for DMEPOS to be even more critical. As we close out the year, it's good to reflect really what does healthcare at home mean for our industry? An Inside Look with Clint, Episode 3: Mark Higley and the Importance of Benchmarking thumbnail An Inside Look with Clint, Episode 3: Mark Higley and the Importance of Benchmarking Clint talks with Mark Higley about the importance of benchmarking. Each year VGM partners with HME News to provide and then analyze an industry benchmark survey.