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CMS clarifies audit plans

CMS clarifies audit plans

WASHINGTON – CMS plans to primarily focus MAC, RAC and SMRC medical reviews on claims with dates of service outside of the public health emergency, the agency stated in a recent clarification

CMS stated: 

“During the PHE, flexibilities were applied across claim types. For certain DME items, this included the non-enforcement of clinical indications for coverage. Since clinical indications for coverage were not enforced for certain DME items provided during the PHE, once the PHE ends CMS plans to primarily focus reviews on claims with dates of service outside of the PHE, for which clinical indications of coverage are applicable.” 

CMS noted that it may still review DME items, as well as other items or services provided during the PHE if needed “to address aberrant behaviors or potential fraud.” The U.S. Department of Health and Human Services and the Office of Inspector General may perform reviews, as well. 

“All claims will be reviewed using the applicable rules in place at the time of the claim dates of services,” CMS stated. 

AAHomecare noted that this is the first guidance that CMS has published regarding audits post-PHE. 

“AAHomecare is pleased to learn that CMS will not be primarily focused on waived claims,” it stated in a bulletin. “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 end of the PHE nears.” 

HHS plans to provide at least 60 days advance notice before ending the PHE. Currently, the PHE is in effect until at least Jan. 1.   


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