MACs’ Post-payment Review Broadened

MACs may now conduct post-payment medical reviews of items and services with dates of service after March 2020.

• By David Kopf
• Jun 03, 2021

CMS has announced that Medicare Administrative Contractors (MACs) can now conduct post-payment reviews of items and services with dates of service after March 2020.

In the most recent edition of its MLN Connects, CSM released the following statement:

“Beginning August 2020, Medicare Administrative Contractors (MACs) resumed post-payment reviews of items and services with dates of service before March 2020. MACs may now begin conducting post-payment medical reviews for later dates of service. The Targeted Probe and Educate program (intensive education to assess provider compliance through up to three rounds of review) will restart later. The MACs will continue to offer detailed review decisions and education as appropriate.”

The portion of that statement that allows “later dates of service” for the post-payment reviews is a potential concern, according to audit expert Wayne van Halem, president of audit consulting firm The van Halem Group.

To understand van Halem’s concern, let’s review a quick timeline:

• Prior to HHS declaring the COVID-19 public health emergency, MACs were conducting pre-payment TPE reviews.
• When the PHE hit, CMS suspended its audits on March 30, 2020.
• Then, in August, CMS began slowly phasing back in various audits.
• As part of that phase-in, CMS said it would only allow post-payment reviews of claims with dates of service before March 2020 (when the PHE began).

“The concern for me regarding this announcement is over what rules the DME MACs are going to apply in these audits,” van Halem said. “The [audit] waivers went into effect after March 2020 and remain in effect.

“The only guidance CMS gave to suppliers over the course of the pandemic was that items must still be ‘reasonable and necessary,’” he added. “That’s pretty general, so I think there is a potential for inconsistencies over what guidelines will be used and how they will be applied.”

For now, there hasn’t been a problem; time will tell if that changes. 

“The MACs know the waivers and should be auditing for only those requirements under the waivers,” saidKim Brummett, vice president of regulatory affairs for the American Association for Homecare.

For more insights into the resumption of Medicare claims audits, recently, in Episode 47 of the HMEB Podcast, van Halem discussed how CMS’s resumption of TPE, RAC and other audits programs is progressing, as well as what expanding resources at OMHA might mean or HME providers.

You can download the episode on iTunes, Stitcher, Google Podcasts, or listen to it here: