CMS: Audits to Return in August

After a five-month reprieve, the Centers for Medicare & Medicaid Services (CMS) says that as of Aug. 3, 2020 it will resume most Medicare Fee-For-Service (FFS) medical reviews that it suspended in March because of the COVID-19 pandemic. This includes 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).

“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,†according to the recently released guidance.

This notice may come as a surprise, given that CMS initially stated that it intended to suspend such reviews until the end of the pandemic. However, the agency pointed to changes in states’ reopening policies and the importance of the reviews as reasons for its decision to resume audits.

Not surprisingly, the decision has resulted in pushback from many in the healthcare industry, particularly those in states where COVID-19 cases continue to surge such as Florida, Texas and Arizona.

CMS also noted the following:

Signature requirements: CMS will not be enforcing the signature requirement. Typically, Part B drugs and certain Durable Medical Equipment covered by Medicare require proof of delivery and/or a beneficiary’s signature. CMS says that suppliers should document in the medical record the appropriate date of delivery and that a signature was not able to be obtained because of COVID-19.

Ambulance service: For claims with dates of service during the COVID- 19 public health emergency (Jan. 27, 2020, until expiration), CMS will not review for compliance with appropriate signature requirements for non-emergency ambulance transports during medical review, absent indication of fraud or abuse. Ambulance providers and suppliers should indicate in the documentation that a signature was not able to be obtained because of the ongoing COVID-19 pandemic.

Repetitive, Scheduled Non-Emergent Ambulance Transport (RSNAT) Prior Authorization Model: CMS will resume full-model operations and prepayment review will resume for repetitive, scheduled non-emergent ambulance transport claims submitted in the model states on or after Aug. 3, 2020, if prior authorization has not been requested by the fourth round trip in a 30-day period. Those model states are: Delaware, the District of Columbia, Maryland, New Jersey, North Carolina, Pennsylvania, South Carolina, Virginia, and West Virginia. Following resumption of the model, the MAC will conduct post-payment review on claims that were subject to the model that were submitted and paid during the pause.

CMS says the RSNAT model is scheduled to end on Dec. 1, 2020 and there are no plans to extend it due to COVID-19.

Review Choice Demonstration for Home Health Services: Certain claims processing for the Review Choice Demonstration (RCD) for Home Health Services were paused in Illinois, Ohio, and Texas. The initial choice selection period will begin in North Carolina and Florida on Aug. 3, 2020 and end on Aug. 17, 2020.  The choice selection period for Ohio’s second review cycle will also begin Aug. 3, 2020 and end on Aug. 17, 2020.

Following these choice selection periods, home health claims in all demonstration states (Illinois, Ohio, Texas, North Carolina, and Florida) with billing periods beginning on or after Aug. 31, 2020 will be subject to review under the requirements of the choice selected. Once the demonstration resumes, the MAC will conduct post-payment review on claims subject to the demonstration that were submitted and paid during the pause. CMS said it will post more information on the post-payment review process in the near future.

Prior Authorization Program for DMEPOS items: CMS will discontinue exercising enforcement discretion on Aug. 3, 2020 and the Prior Authorization Program will resume for certain DMEPOS. For an updated list of items that require prior authorization click here.

Despite the fact that there does not seem to be an easing of the pandemic, CMS has made it clear that its enforcement efforts will resume in full force. The Health Law Offices of Anthony C. Vitale has experience representing clients in audits and overpayments through all of the stages of the process. Give us a call at 305-358-4500 or email info@vitalehealthlaw.com.