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.


TAGS

  1. audits
  2. cms
  3. the van halem group
  4. vgm

comments powered by Disqus

From Our Experts

Understanding Enrollment Status, Assigned vs. Non-Assigned, and the ABN thumbnail Understanding Enrollment Status, Assigned vs. Non-Assigned, and the ABN A major part of business development is understanding your payer mix and which products and services should be reimbursable versus cash sale items. What could you bundle together in your offering to expand business—specifically items that can be sold for retail alongside your reimbursable items? You might not necessarily offer everything right now, but these are the areas you can look to expand into. This resource outlines how to navigate reimbursement to help grow your business. U.S. Rehab Tech Training at Heartland Addresses All Levels of Experience thumbnail U.S. Rehab Tech Training at Heartland Addresses All Levels of Experience Complex rehab providers attending VGM's 20th Heartland Conference will have the opportunity to increase their expertise in repairing and programming complex rehab wheelchairs as part of U.S. Rehab's Tech Training. VGM & Associates Releases Customer-Centric Playbook thumbnail VGM & Associates Releases Customer-Centric Playbook VGM & Associates has released the third installment of their 2021 quarterly playbook series, which contains insight and best practices for making your business customer-centric. Heartland Session Sneak Peek: Procurement, Inventory Management & Cash Flow thumbnail Heartland Session Sneak Peek: Procurement, Inventory Management & Cash Flow Get great advice and more during the Heartland Conference Panel: Procurement, Inventory Management & Cash Flow moderated by Gerry Finazzo. During this session, attendees will learn how to identify ways to improve purchasing practices, mitigate inventory liability, identify ways to increase cash flow and lower activity costs. An Inside Look with Clint, Episode 8: VGM Government thumbnail An Inside Look with Clint, Episode 8: VGM Government President of VGM & Associates, Clint Geffert, sat down with John Gallagher, vice president of VGM Government, to discuss how VGM Government helps VGM members navigate the complexities of the legislative process and the importance of grassroots advocacy in the HME industry. Member Spotlight: Shelly Hoover, President and Co-Founder, and David Hoover, CEO and Co-Owner of Vets First DME, LLC thumbnail Member Spotlight: Shelly Hoover, President and Co-Founder, and David Hoover, CEO and Co-Owner of Vets First DME, LLC Vets First DME began at the intersection of preparation and opportunity, with a dash of circumstance. Read more about the amazing Hoover family as they combined the family's knowledge and experience to start Vets First DME, LLC. CMS Announces 90-Day Extension For CRT Manual Wheelchair Accessories thumbnail CMS Announces 90-Day Extension For CRT Manual Wheelchair Accessories CMS announced a 90-day extension of the suspension of the application of Medicare Competitive Bidding Program pricing to CRT manual wheelchair accessories. The current policy will stay in place through October 1 and there will not be any payment cuts or claims processing changes. Don't Allow Medicare Advantage Plans and MCOs Take Advantage of YOU! thumbnail Don't Allow Medicare Advantage Plans and MCOs Take Advantage of YOU! The HME supplier has always had challenges in getting paid timely and accurately for the items and services they provide to their customers. This is an assumed cost of doing business but the HME supplier still does this because of the reward of taking care of their customers. But nothing has challenged the supplier as much as when a customer has a Medicare Advantage Plan or an MCO.