CMS Publishes Post-PHE Audit Guidance

In the first guidance on how it will handle audits after the Covid-19 public health emergency, CMS offers clarifications on dates of service and the nature of the audits.

• By David Kopf
• Nov 10, 2022

CMS has released its first official guidance concerning how it will handle Medicare claims audits after the end of the Covid-19 public health emergency (PHE).

According to CMS, the guidance would impact how Medicare Administrative Contractors (MACs), Recovery Audit Contractors (RACs) and the Supplemental Medical Review Contractor (SMRC) plan to conduct medical reviews post-PHE.

During the PHE, CMS applied policy flexibilities across various types of claims. That flexibility included not enforcing clinical indications for coverage for claims on certain DME items provided during the PHE, according to CMS.

Because it implemented those flexibilities, CMS said that once the PHE ends, it plans to have audit contractors 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,” CMS guidance read. “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.”

“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 the end of the PHE nears,” a statement from the American Association for Homecare read.

So when does the PHE end? At present, the date when the Covid-19 PHE ends is unknown. In late October, Secretary of Health and Human Services Xavier Becerra extended the Covid-19 PHE for another 90 days until Jan. 11, 2023.

We also know that in a May 10 letter to U.S. governors, Becerra reaffirmed HHS’s commitment to providing at least 60 days advance notice before ending the PHE. Based on that information, it can be assumed that all eyes will be on HHS in roughly a week or two to see if HHS will give that notice. If not, we can assume there will be another extension.

But what is making some people expect the PHE to end is the fact that in late August, CMS released a summary “roadmap” and other resources to help providers and suppliers start preparing for the regulatory environment that will come after the Covid-19 public health emergency ends. It’s likely CMS wouldn’t make such an announcement, or the recent audit guidance, without an end to the PHE coming into focus.

For now, all eyes are on HHS for that 60-day notice.