CMS To Resume Medical Reviews This Month

POSTED ON MONDAY, August 17, 2020

CMS will resume medical reviews this month, after suspending most of them on March 30th due to COVID-19.

“All the Medicare Administrative Contractors (MACs) for home health and hospice have published information indicating that medical reviews will resume. National Government Services (NGS) has shared some details with NAHC about this resumption which are summarized below. All MACs are expected to be consistent with these.

• MACs will resume post payment medical reviews. This is different than the Targeted Probe & Educate (TPE) program. CMS has not provided any direction to the MACs thus far regarding the resumption of TPE. It is only post payment medical reviews that will be conducted at this time.
• The post payment reviews are service specific (as opposed to provider specific) and will be a random sample. A service specific review is one where the MAC is focused on the claim and not the provider.
• CMS has given a resumption date of August 17, 2020. It is anticipated that providers will begin receiving ADRs later that week.
• The timeframe from which NGS will pull claims is January 2019 through February 29, 2020. At the time of this writing it is not clear if the other MACs will use this same period; however, it is our understanding that MACs have been instructed by CMS to not pull claims from March 1, 2020 forward.
• The maximum number of claims to be pulled per provider is 20. There is no minimum. This is less than the total number under the TPE program, and a provider may or may not receive ADRs for a full 20 claims. It is anticipated that the majority of hospice and home health providers will not have this many claims pulled. Any providers having difficulty responding to the ADRs timely should contact their MAC. MACs may be able to work with the provider if the provider makes them aware of the situation.
• NGS indicated it will post on its website a brief description of the service specific audits and Additional Documentation Requests (ADRs) will be sent approximately 2-3 days after this posting. It is anticipated that the other MACs will follow this same process but as of the time of this writing that has not been confirmed.
• Providers should not wait to receive an ADR request in the mail but should check the status of their claims processing and identify any with the S B6001 status. These are claims that have had an ADR generated. MACs will still mail an ADR, but as known from past experience, many of these mailed ADRs are not received by the provider/the correct individual at the provider. Again, it is best for the provider to check the status of their claims processing.
• The MAC has 60 days to review the provider’s response to the post payment ADR. Providers still have 45 days to respond to the ADR, although observing a 30-day response is strongly suggested to ensure that the response is received and recorded by the 45th day.
• A results letter will be sent after each claim is reviewed.
• A provider may request education and the MAC may suggest education. Even though education may be requested or suggested, a provider is not required to participate in education.
• The error rate (payment error rate or claim error rate) is not as important with a service specific post payment review as it is with TPE since there are no “rounds” in post payment review as there are with TPE. The MACs are not setting error rate thresholds upon which further MAC action is predicated. As with all medical reviews, if the MAC identifies a concern, i.e. a quality concern or indication of potential fraud or abuse, the MAC will refer to the appropriate entity (i.e. the appropriate QIO or the division of CMS).
• MACs will continue to make phone calls to providers for missing documentation or questions about documentation submitted.”

Source: NAHC Report


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