CMS Suspends Medical Review in response to COVID-19

  • 31 Mar 2020 8:50 AM
    Message # 8869972
    Anonymous member (Administrator)

    CMS has posted FAQs at: that outline a cessation of medical reviews due to the COVID emergency.  Following is a relevant excerpt:

    Q.  Is CMS suspending most Medicare Fee-For-Service (FFS) medical review during the Public Health Emergency (PHE) period for the COVID-19 pandemic?

    A.  Yes, CMS has suspended most Medicare Fee-For-Service (FFS) medical review during the emergency period due to the COVID-19 pandemic. This includes 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 (SMRC) reviews and Recovery Audit Contractor (RAC). No additional documentation requests will be issued for the duration of the PHE for the COVID-19 pandemic. Targeted Probe and Educate reviews that are in process will be suspended and claims will be released and paid. Current postpayment MAC, SMRC, and RAC reviews will be suspended and released from review. This suspension of medical review activities is for the duration of the PHE. However, CMS may conduct medical reviews during or after the PHE if there is an indication of potential fraud.

    Further in the Q & A, CMS announces intent to pause the Review Choice Demonstration:

    Q. Is CMS pausing the Review Choice Demonstration for Home Health Services?

    A. Yes. Effective March 29, 2020, certain claims processing for the Review Choice Demonstration (RCD) for Home Health Services will be paused in Illinois, Ohio, and Texas, until the PHE for the COVID-19 pandemic has ended. During the pause, the MACs will process claims submitted prior to the emergency period under normal claims processing requirements. Claims for home health services furnished on or after March 29, 2020 and before the end of the PHE for the COVID-19 pandemic in these states will not be subject to the review choices made by the home health agency under the demonstration. However, the MAC will continue to review any pre-claim review requests that have already been submitted, and providers may continue to submit new pre-claim review requests for review during the pause. Claims that have received a provisional affirmative pre-claim review decision and are submitted with an affirmed Unique Tracking Number (UTN) will continue to be excluded from future medical review. Home health agencies participating in pre-claim review may submit their claims without requesting such approval from the MAC and claims submitted without a UTN will not be stopped for prepayment review and will not receive a 25% payment reduction. HHAs participating in the other review choices (prepayment or postpayment review) will not receive Additional Documentation Requests (ADRs) during the pause, and ADRs that were issued prior to the PHE will be released and processed as normal. Following the end of the PHE for the COVID-19 pandemic, the MAC will conduct postpayment review on claims subject to the demonstration that were submitted and paid during the pause. The demonstration will not begin in North Carolina and Florida on May 4, 2020, as previously scheduled. CMS will provide notice on its demonstration website rescheduling the start of the demonstration, once the PHE has ended.

    Q. The demonstration is currently scheduled to end on May 31, 2024. Given this pause, will CMS extend the demonstration beyond that date?

    A. At this time, CMS is not planning an extension beyond May 31, 2024. If this did occur, CMS would provide proper public notice.

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