July 24, 2020

The Centers for Medicare and Medicaid Services (“CMS”) announced that it plans to resume pre-payment and post-payment medical review activity on August 3, 2020, regardless of the public health emergency status. CMS originally suspended most Medicare Fee-For-Service medical reviews because of the COVID-19 pandemic. This suspension included pre-payment medical reviews conducted by Medicare Administrative Contractors (MACs) under the Targeted Probe and Educate program, and post-payment reviews conducted by the MACs, Supplemental Medical Review Contractor reviews and Recovery Audit Contractors. In a COVID-19 Provider Burden Relief Frequently Asked Questions (“FAQ”) document, CMS explained that it intends to discontinue exercising enforcement discretion in August because of “the importance of medical review activities to CMS’ program integrity efforts.”


Providers should be attentive to any contractor notifications regarding payment reviews as well as be prepared to potentially engage in audit processes and activities. 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 makes clear that all reviews will … conducted in accordance with statutory and regulatory provisions, as well as related billing and coding requirements. However, CMS notes that auditors will apply any waivers and flexibilities that were in place at the time of the dates of service of any claims selected for review.

If you have any questions or require assistance with a medical review, please contact a member of Hancock Daniel’s Compliance team.

Click here for a full PDF of this advisory.

The information contained in this advisory is for general educational purposes only. It is presented with the understanding that neither the author nor Hancock, Daniel & Johnson PC, is offering any legal or other professional services. Since the law in many areas is complex and can change rapidly, this information may not apply to a given factual situation and can become outdated. Individuals desiring legal advice should consult legal counsel for up-to-date and fact-specific advice. Under no circumstances will the author or Hancock, Daniel  & Johnson PC be liable for any direct, indirect, or consequential damages resulting from the use of this material.

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