Complete Story


CMS Releases Additional Guidance on Post-PHE Medical Reviews

Breaking News from AAHomecare 11/10/2022


Today, CMS published a clarification regarding post-PHE medical review audits. The following is direction from the publication (emphasis by AAH):

Q. At the end of the Public Health Emergency (PHE) how will CMS’ review contractors conduct medical reviews for claims billed during the PHE based on approved waivers or flexibilities?

A. CMS contractors (MACs, RACs, and SMRC) review a very small percentage of Medicare Fee-for-Service claims each year. During the PHE, flexibilities were applied across claim types. For certain DME items, this included the non-enforcement of clinical indications for coverage. Since clinical indications for coverage were not enforced for certain DME items provided during the PHE, once the PHE ends CMS plans to primarily focus reviews on claims with dates of service outside of the PHE, for which clinical indications of coverage are applicable. We note that we may still review these DME items, as well as other items or services rendered during the PHE, if needed to address aberrant billing behaviors or potential fraud. The HHS-Office of the Inspector General may perform reviews as well. All claims will be reviewed using the applicable rules in place at the time for the claim dates of service.

This is the first public guidance CMS has published regarding audits after the end of the PHE. AAHomecare is pleased to learn that CMS will not be primarily focused on waived claims. Suppliers can find additional information by CMS regarding Medicare compliance program here

AAHomecare has been in contact with CMS concerning the transition out of the PHE and will continue to work with CMS and Medicare contractors as end of the PHE nears.  HHS has stated its intention to provide at least 60 days advance notice for when the Agency plans to end the PHE, which is currently in effect until at least January 11, 2023.

Printer-Friendly Version