Medicare program resuming fee-for-service audits and DMEPOS prior authorization program paused during COVID-19 pandemic

Despite many parts of the country seeing upticks in COVID-19 cases and hospitalizations, the Centers for Medicare & Medicaid Services (CMS) is ready to get back to some of its normal oversight activities related to the Medicare program. CMS quietly announced via an updated Frequently Asked Questions (FAQ) document posted on its website that its contractors will resume audits as of August 3, 2020. CMS previously suspended most Medicare fee-for-service medical reviews because of the COVID-19 pandemic. These reviews included pre-payment reviews conducted by Medicare Administrative Contractors (MACs) under the Targeted Probe and Educate program and post-payment reviews conducted by MACs, the Supplemental Medical Review Contractor and Recovery Audit Contractors. However, the audits will restart on August 3, 2020, “regardless of the status of the public health emergency.”  

If selected for review, CMS suggests that providers discuss with the contractor performing the review “any COVID-19-related hardships they are experiencing that could affect audit response timeliness.” The updated FAQ also notes that “all reviews will be conducted in accordance with statutory and regulatory provisions, as well as related billing and coding requirements [and that w]aivers and flexibilities in place at the time of the dates of service of any claims potentially selected for review will also be applied.” This comment makes it clear that services rendered and claims submitted during the COVID-19 public health emergency are fair game for these Medicare contractors.

In the same FAQ document, CMS also announced the resumption of its Prior Authorization Program for Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) items. CMS stated that it “will resume full operations for the prior authorization program for certain DMEPOS items.” Specifically, 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.”

Bricker previously published an article detailing the restart of the Review Choice Demonstration for Ohio home health agencies, which was also announced in the FAQ document and also restarts on August 3, 2020.