Back to Business AUG 3rd... Prior Auths, Audits, & other Medicare biz

CMS is planning on rolling back some of the flexibilities currently in place to assist providers during the COVID-19 PHE to ensure CMS program integrity.  

  • CMS audits are expected to resume on August 3rd, regardless of the status of the PHE.  
    • The initial announcement stated that this included TPE, post payment reviews conducted by the MACs, Supplemental Medical Review Contractor (SMRC) reviews and Recovery Audit Contractor (RAC) audits.  However, following intervention by AAHomecare this statement has since been adjusted and audits will now begin with DME MAC post-pay reviews only, in order to allow for more flexibility and to avoid holding up payments.
    • There is currently no timeline for TPEs, RAC or SMRC audits to restart.
    • CMS has also stated that the audits will start on a delayed timeframe, so suppliers should not expect to see audit requests come through right away on August 3rd.
    • DME MACs will not be pulling claims which started during the PHE at this time, only claims prior to March 1st, 2020.
    • If selected, providers should let their contractor know of any COVID-10-related difficulties which could affect audit response times.  CMS is tracking state and county-level COVID-19 cases and will be sharing this information with the MACs to be taken into consideration.
  • Enforcement discretion of Prior Authorization requirements is expected to be discontinued on August 3rd, regardless of the status of the PHE.  For Power Mobility Devices and Pressure Reducing Support surfaces which require prior authorization, claims with an initial DOS on or after August 3rd, 2020 must be associated with an approved prior authorization to be eligible for payment.  The full list of items for which CMS requires prior authorization can be found here.
  • Prior Authorization for certain Lower Limb Prosthetics (LLPs), codes L5856, L5857, L5858, L5973, L5980, and L5987 will be required for dates of service on or after September 1st, 2020 in California, Michigan, Pennsylvania, and Texas.  For patients in the remaining states and territories, prior authorization for these codes will be required for dates of service on or after December 1st, 2020.