NOTE: All in-article links open in a new tab.

Medical Reviews during the COVID-19 Public Health Emergency

Published on 

Tuesday, August 11, 2020

 | FAQ 


Have Medicare Contractors started performing Medical Reviews again?


On July 6, 2020, CMS released the document Coronavirus Disease 2019 (COVID-19) Provider Burden Relief Frequently Asked Questions (FAQs). The very first FAQ addresses Medicare Fee-for-Service medical reviews.


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

A. On March 30 CMS suspended most Medicare Fee-For-Service (FFS) medical review because of the COVID-19 pandemic. This 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 (SMRC) reviews and Recovery Audit Contractor (RAC). As states reopen, and given the importance of medical review activities to CMS’ program integrity efforts, CMS expects to discontinue exercising enforcement discretion beginning on August 3, 2020, regardless of the status of the public health emergency. If selected for review, providers should discuss with their contractor any COVID-19-related hardships they are experiencing that could affect audit response timeliness. CMS notes that all reviews will be conducted in accordance with statutory and regulatory provisions, as well as related billing and coding requirements. Waivers and flexibilities in place at the time of the dates of service of any claims potentially selected for review will also be applied.

American Hospital Association Letter to CMS

The American Hospital Association (AHA) expressed concern about CMS’s decision to resume medical review audits on August 3, 2020 in a July 29, 2020 letter to CMS Administrator Seema Verma. The letter ends with the AHA stating that “to be clear, we urge the agency to refrain from differentiation between medical review audits and the other flexibilities you have created, and instead ensure all of the relevant waivers remain active during the pandemic.”

Medicare Administrative Contractors (MACs) Guidance

On August 4, 2020, Palmetto GBA posted an article to their website providing additional detail about the resumption of medical reviews. Specifically,

  • Beginning August 17th, the MACs are resuming post-payment reviews of items/services provided prior to March 1, 2020,
  • The Targeted Probe and Educate (TPE) program will restart later, and
  • MACs will continue to offer detailed review decisions and education as appropriate.

CMS included this same guidance in their August 6, 2020 MLNConnects e-newsletter.

Article Author: Beth Cobb, RN, BSN, ACM, CCDS
Beth Cobb, RN, BSN, ACM, CCDS, is the Manager of Clinical Analytics at Medical Management Plus, Inc. Beth has over twenty-five years of experience in healthcare including eleven years in Case Management at a large multi-facility health system. In her current position, Beth is a principle writer for MMP’s Wednesday@One weekly e-newsletter, an active member of our HIPAA Compliance Committee, MMP’s Education Department Program Director and co-developer of MMP’s proprietary Compliance Protection Assessment Tool.

This material was compiled to share information.  MMP, Inc. is not offering legal advice. Every reasonable effort has been taken to ensure the information is accurate and useful.