Audits will not resume full bore

Tuesday, July 21, 2020

WASHINGTON – When program integrity activities resume on Aug. 3, CMS will not be auditing claims started during the public health emergency, industry stakeholders have learned.

Both the van Halem Group and AAHomecare reported this week that the agency will focus its activities, at least initially, on claims started sometime prior to March 1.

Stakeholders have also learned that CMS plans to take a phased approach to resuming reviews, starting with RAC audits and then moving to SMRC audits, both of which have been suspended since March.

“In recent meetings with CMS, we have learned that, while the date to begin medical review functions is Aug. 3, there will likely be a delayed time frame before audit requests officially go out,” wrote Kelly Grahovac in a Van Halem Group Blog. “CMS is currently working to develop instructions for contractors and intends to take a ‘toe in the water’ approach, as opposed to opening up a flood gate of audits.”

Other details gathered by stakeholders:

  • CMS will allow extensions and the cancellations of audits based on a supplier’s ability to complete them.
  • TPE audits will not be included at this time.

“This makes sense, as TPE audits are pre-pay reviews and, due to claim processing system limitations, there are less flexibilities to grant extensions for those suppliers that would need more time to respond,” Grahovac wrote. “CMS has made it clear that during this pandemic they do not want to hold up payments for suppliers. As such, there is no time frame given for the restart of the TPE.”

CMS announced plans to resume audits in a COVID-19 Provider Burden Relief FAQ earlier this month.