CMS implements audit improvements

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Friday, April 28, 2017

WASHINGTON – CMS has announced significant improvements to the processing of serial claims for capped rental items and certain inexpensive and non-routinely purchased items, according to a bulletin from AAHomecare.

It’s an issue that has been a challenge for providers for years and contributed to the massive appeals backlog, the association says.

Improvements include:

  • Instructing the DME MACs to change the process by which they adjudicate appeals of serial claims. Once the reason for denial for one claim in a series is resolved at any appeal level, the DME MACs will identify other claims in the same series that were denied for the same or similar reasons, and take that determination into consideration when adjudicating such claims. 
  • The DME MACs will also communicate favorable decision(s) to the DME QIC and the Office of Medicare Hearings and Appeals (OMHA) to consider when adjudicating related appeals pending at those levels. 
  • Instructing the DME MACs to update the CMN in the ViPS Medicare System (VMS), when appropriate, to reflect when a favorable decision has been rendered for a serial claim, allowing future claims in the same series to pay without requiring suppliers to continually resubmit evidence.
  • Instructing the DME MACs to perform data analysis of all favorable serial claim appeal decisions made over the past three years, in an effort to capture all currently pending appeals in the series that could be included in this initiative. Suppliers do not need to take any action and should not reach out to the DME MAC within their jurisdiction to request that their appeal be considered for this initiative. 
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