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Earlier today in a Listserv announcement, CGS announced that the Jurisdiction B Medical Review department would begin complex post-pay service-specific reviews on two codes: L0650 and A4253. Both reviews are a result of data analysis that indicate Jurisdiction B's allowed dollars for HCPCS L0650 and A4253 were significantly above expected amounts. Further, each code ranks high in the CERT Errors Top 15, with the L0650 ranking #6 and the A4253 at #11.

Based on earlier information shared by CMS, post-payment reviews will be on items/services provided before March 1, 2020. If you have provided this type of DMEPOS prior to the pandemic health emergency (PHE) in Jurisdicition B your claims may be susceptible to audit.

Interestingly enough is the "reminder" in paragraph two that states: CGS would like to remind suppliers of the importance of responding to Additional Documentation Request (ADR) letters. Authorization for the collection of this information is included in Federal Law at SSA 1833 (e) and in Federal regulation at 42 CFR 424.5(a)(6). Suppliers are in violation of Supplier Standard #28 when, upon request, they fail to provide requested documentation to a Medicare contractor. Therefore, the consequences of failure to provide records may not only be a claim denial but also referral to the National Supplier Clearinghouse (NSC).

A referral to the NSC will likely result in unannounced site inspection visits or even investigations by their Supplier Audit and Compliance Unit (SACU). Violations of DMEPOS Supplier Standards can result in revocation of your supplier number for a minimum of one year.

If you are a supplier who is experiencing a COVID-19 related hardship that may affect audit response timeliness, you are instructed to contact the DME MAC, per earlier directives from CMS.

It is important to note that the links provided in the announcement were inactive when attempting to 'click through' and this information could not be located on the Jurisdiction B website at the time this post was published. The van Halem Group will continue to monitor this and provide updates as needed.

Want to be ‘audit ready’? The van Halem Group can help!

From clinical prescreens of your claims to conducting proactive audits on a one-time or monthly basis, we have solutions to ensure your claims are audit ready and meet technical and clinical guidelines. Contact us to learn what our team of experts can do for you!