Audits Set to Resume August 3, Updated FAQs On COVID-19 Provider Burden Relief

Published in Women's Health on July 20, 2020

August 3 seems to be an important date for CMS. On August 3, the DME MACs, SMRC, and RAC will be able to resume audit activity.

Here is a recent update from the “Coronavirus Disease 2019 (COVID-19) Provider Burden Relief Frequently Asked Questions (FAQs)” that are attached as well. Prior Authorizations will resume as business as usual for PMDs and Group 2 Support Surfaces. Also, the lower limb prosthetics (6 codes) will begin prior authorization activity with a phased approach with Phase 1 starting Sept 1, 2020.

If you have questions about these updates, contact Ronda Buhrmester.

Q. Is CMS suspending most Medicare Fee-For-Service (FFS) medical review during the Public Health Emergency (PHE) for the COVID-19 pandemic?

A. On March 30th, CMS suspended most Medicare Fee-For-Service (FFS) medical review because of the COVID-19 pandemic. This included pre-payment medical reviews conducted by Medicare Administrative Contractors (MACs) under the Targeted Probe and Educate program, and post-payment reviews conducted by the MACs, Supplemental Medical Review Contractor (SMRC) reviews and Recovery Audit Contractor (RAC). 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. If selected for review, providers should discuss with their contractor any COVID-19-related hardships they are experiencing that could affect audit response timeliness. CMS notes that all reviews will be conducted in accordance with statutory and regulatory provisions, as well as related billing and coding requirements. Waivers and flexibilities in place at the time of the dates of service of any claims potentially selected for review will also be applied

Q. When is CMS resuming the Prior Authorization Program for DMEPOS items?

A. 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. CMS will resume full operations for the prior authorization program for certain DMEPOS items. For Power Mobility Devices and Pressure Reducing Support Surfaces that require prior authorization as a condition of payment, claims with an initial date of service on or after August 3, 2020, must be associated with an affirmative prior authorization decision to be eligible for payment. For an updated list of items that require prior authorization please visit: https://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/Medicare-FFS-Compliance-Programs/DMEPOS/Downloads/DMEPOS_PA_Required-Prior-Authorization-List.pdf

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