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.

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