Health Law Scan

Legal Insights and Perspectives for the Healthcare Industry

The Centers for Medicare and Medicaid Services (CMS) recently announced that it intends to resume both prepayment and postpayment medical reviews conducted by the Medicare Administrative Contractors, Supplemental Medical Review Contractors, and Recovery Audit Contractors, including those under the Targeted Probe and Educate program, on August 3, 2020:

As states reopen, and given the importance of medical review activities to CMS’ program integrity efforts, CMS expects to discontinue exercising enforcement discretion beginning on August 3, 2020, regardless of the status of the public health emergency. (Emphasis added.)

CMS had suspended most Medicare audits and reviews as of March 30, 2020 due to the coronavirus (COVID-19) pandemic.

If selected for review, providers should discuss with their contractors any COVID-19-related hardships they are experiencing that could affect audit response timeliness, according to the agency. According to CMS, auditors will be “applying” any waivers and flexibilities in place during the emergency period as they conduct their claims reviews, which otherwise will follow statutory and regulatory provisions and billing and coding requirements.

The CMS announcement was released in a document titled Coronavirus Disease 2019 (COVID-19) Provider Burden Relief Frequently Asked Questions that in part addresses the resumption of certain medical review activities that have been paused by the agency since March 30.