CMS to Resume Medicare Audits, Prior Authorization on Aug. 3

Postponed since March 30, TRP, SMRC and RAC audits will restart next month, as will prior authorization for PMDs and support surfaces.

• By David Kopf
• Jul 16, 2020

CMS will lift its suspension of Medicare claims audits and will resume prior authorization for power mobility devices and support surfaces on Aug. 3, according to an update to its FAQ on COVID-19 provider burden relief.

Implemented on March 30, the suspension put a pause on DME MAC Targeted Probe and Education, Supplemental Medical Review Contractor (SMRC) reviews and Recovery Audit Contractor (RAC) audits. In its FAQ update, CMS cited the changes in state COVID-19 policies and the importance placed on program integrity as reasons for resuming the audits.

“If selected for review, providers should discuss with their contractor any COVID-19-related hardships they are experiencing that could affect audit response timeliness,” the FAQ reads. “CMS notes that all reviews will be conducted in accordance with statutory and regulatory provisions, as well as related billing and coding requirements. Waivers and flexibilities in place at the time of the dates of service of any claims potentially selected for review will also be applied.”

When it comes to prior authorization, CMS stated that it will resume the program “regardless of the status of the public health emergency.” Claims with a date of service on or after Aug. 3 have an affirmative prior authorization decision to be eligible for payment. CMS also posted a full list of items with HCPCS codes the program covers.

CMS is making the move as the nation is experiencing increases in the rate of COVID-19 diagnoses, hospitalizations and deaths. Moreover, when CMS initially paused these programs, it said it would do so for the length of the Public Health Emergency. Given these circumstances, the resumption drew pushback from the industry.

“With COVID-19 cases rising dramatically across the nation, HME suppliers remain fully engaged in treating patients with COVID-19 and helping reduce the pressure on hospitals and clinicians during this pandemic,” said Tom Ryan, president and CEO of the American Association for Homecare. “This isn’t the right time to resume audit activity and ramp up paperwork demands for the HME community.

“Many HME suppliers are more stressed by the pandemic now than they were in April and May,” he continued. “… The facts on the ground make it clear that we’re a long way away from ‘business as usual’ in the healthcare sector. CMS needs to pause or at least significantly limit audit activity until the COVID-19 Public Health Emergency is over.”

AAHomecare reported it is working on this issue and will be sharing industry concerns with CMS.