CMS limits scope of audits

Tuesday, September 1, 2015

WASHINGTON – For redeterminations and reconsiderations of claims denied following a post-payment review or audit, CMS has instructed the MACs and QICs to limit their scope to the reason the claim or line item was initially denied, according to a recent MLN Matters article.

In the past, the MACs and QICs have had the discretion to develop new issues and review all aspects of coverage and payment related to a claim or line item.

“In some cases, where the original denial reason is cured, this expanded review of additional evidence or issues results in an unfavorable appeal decision for a different reason,” CMS states in MLN Matters Number: SE1521.

The guideline applies to redeterminations and reconsiderations received by the MACs or QICs on or after Aug. 1, 2015. It will not be applied retroactively.

CMS points out, however, that there are two instances where the guideline does not apply: 1.) claims denied in prepayment reviews (the guideline applies only to post-payment denials); and 2.) claims denied in post-payment review for insufficient documentation and appealed with never-before presented documents (the guideline allows these claims to be denied for an issue other than the issue that was initially denied).