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The CMS Center for Program Integrity (CPI) posted an FAQ this week on their Spotlight page titled “Medicare Fee-for-Service Claims Review When the Public Health Emergency Ends”. From the post...

Q. At the end of the Public Health Emergency (PHE) how will CMS’ review contractors conduct medical reviews for claims billed during the PHE based on approved waivers or flexibilities?

A. CMS contractors (MACs, RACs, and SMRC) review a very small percentage of Medicare Fee-for-Service claims each year. During the PHE, flexibilities were applied across claim types. For certain DME items, this included the non-enforcement of clinical indications for coverage. Since clinical indications for coverage were not enforced for certain DME items provided during the PHE, once the PHE ends CMS plans to primarily focus reviews on claims with dates of service outside of the PHE, for which clinical indications of coverage are applicable. We note that we may still review these DME items, as well as other items or services rendered during the PHE, if needed to address aberrant billing behaviors or potential fraud. The HHS-Office of the Inspector General may perform reviews as well. All claims will be reviewed using the applicable rules in place at the time for the claim dates of service.

The van Halem Group is among several industry stakeholders that have been working with CMS to assist with developing guidance to audit contractors related to the equipment categories affected by the waivers and flexibilities in effect during the PHE. The PHE is currently in effect until January 11, 2023, at which point, the Secretary of Health and Human Services may announce another extension.

Until that time, we advise that suppliers operate in a pre-pandemic, “business as usual” manner. Translation: suppliers should review the coverage and documentation requirements for the equipment they provide to their Medicare beneficiaries and ensure they are obtaining the required documentation. In the event a supplier needs to rely on any of the PHE waivers still in effect, it is imperative that you are appropriately documenting why a required element was not met. 

If you receive an audit request, the van Halem Group can help! Our team of experts can review your patient files prior to submission and provide valuable feedback to ensure your audit response is complete and concise. Following the results of the audit, our appeals team can assist with appeals in the event an overpayment as been identified. Contact us today for more information.