01.18.2023

CMS shares plans for medical review when PHE ends

The nation’s COVID-19 Public Health Emergency has been extended through April, but the Centers for Medicare and Medicaid Services (CMS) has begun offering guidance and resources for when the PHE ends.

The most recent post-PHE information from CMS is a new resource page explaining plans for conducting medical review post-PHE. CMS made the resource page available late in 2022.

On Jan. 11, U.S. Department of Health and Human Services Secretary Xavier Becerra signed another 90-day extension of the PHE, which means home health and hospice agencies will be allowed to continue operating under COVID-19 waivers and flexibilities into the second quarter of 2023.

Although many current waivers and flexibilities now available to providers will end when the PHE eventually expires, there are some exceptions. One exception will be the face-to-face encounter between patient and physician.

“Providers will have an additional 151 days beyond the last day of the COVID-19 PHE to continue relying on telehealth to meet F2F requirements,” Skehan said.

CMS clarified in September that it will follow provisions enacted by Congress in the Consolidated Appropriations Act of 2022 (CAA 2022). The act extends F2F telehealth waivers for both home health and hospice.

Additional exceptions surround home health aide training and supervision.


Medical review when PHE ends

The new post-PHE resource made available by CMS explains how Medicare Administrative Contractors (MACS), Recovery Audit Contractors (RACs), and the Supplemental Medical Review Contractor (SMRC) plan to conduct medical reviews when the PHE ends.

In general, CMS said, it does not intend to focus reviews on claims with dates of service during the PHE, when certain waivers and exceptions were in place.

An exception to this plan will be medical review to assess aberrant billing behaviors or potential fraud. The U.S. Department of Health and Human Services Office of Inspector General may perform medical reviews as well.
 
“CMS said all claims reviewed will use the applicable rules in place at the time of dates of service on the claim” Skehan said.

Additional information about post-PHE medical review may be found here.


Post-PHE medical review exception   

Skehan is not surprised that CMS plans to allow medical reviews to be conducted on claims with dates of service during the PHE in cases of aberrant billing behaviors or potential fraud on claims.

She said this plan underscores the OIG’s previously stated interest in cracking down on providers who may have taken advantage of the pandemic to cheat the system.

All providers are feeling the fallout from increasing Medicare audits, including those who did not necessarily intend to file fraudulent claims, Skehan said.  

“We are seeing increasing numbers of audits and investigations,” she said. 
“Compliance needs to be at the forefront of every home health and hospice organization right now.”

She recommends agencies insulate themselves with a full compliance assessment to identify vulnerabilities and take steps to reduce the risk of time-consuming and costly audits.

Read more about compliance assessments here.


SimiTree can help

 
SimiTree’s compliance and regulatory team is made up of clinical experts with extensive experience across the healthcare spectrum.

With certification from accrediting organizations such as CHAP and ACHC, SimiTree team members are current, former and certified surveyors who provide best-in-the-industry comprehensive compliance and regulatory support to meet all an organization’s needs.

Team members have successfully handled audits and appeals at all levels, including serving as expert witnesses. SimiTree is authorized as an Independent Review Organization (IRO) by the OIG for Corporate Integrity Agreements (CIAs.)         

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