Tag: Audits

WASHINGTON – The DME MACs are moving forward with audits for claims filed after March 2020, when COVID-19 hit the U.S. and certain waivers went into effect, but audit experts don’t anticipate any widespread problems.  Early in the pandemic, CMS temporarily waived several requirements, including coverage criteria, face-to-face requirements and delivery signatures for respiratory equipment.   “The MACs have been easing into audits since last August, even though...

NASHVILLE, Tenn. – CGS will be conducting complex post-pay, service-specific medical review of lower limb prostheses, L5700 and L5701, the contractor announced on March 19. “This review will be conducted because data analysis revealed that Jurisdiction C’s allowed dollars for L5700 and L5701 were significantly above expected amounts,” CGS stated. “Additionally, the orthotics policy group ranked No. 1 in total comprehensive error rate testing (CERT) errors.”...

NASHVILLE, Tenn. - CGS has announced two more widespread post-pay, service-specific reviews for ostomy supplies and therapeutic shoes/inserts. For ostomy supplies, the codes affected are A4431, A4434, A5081, A5122. CGS says data analysis showed Jurisdiction C's allowed dollars for these codes were significantly above expected amounts. Additionally, these codes were consistently ranked in the top 20 for CERT errors. For therapeutic shoes/inserts, the codes affected are A5500 and A5512 through A5514....

WASHINGTON - CGS, the DME MAC for jurisdictions B and C, will be conducting complex post-pay reviews for surgical dressings and knee orthoses, according to AAHomecare. CGS will be reviewing A6196 and A6212, and L1833 and L1851. The DME MAC is conducting the reviews due to data analysis that showed “significantly above expected amounts.” Surgical dressings and knee orthoses also ranked No. 5 and No. 9, respectively, in total CERT improper payment rates. The reviews will include only claim...

WASHINGTON - CGS, the DME MAC for jurisdictions B and C, will be conducting complex post-pay reviews for surgical dressings and knee orthoses, according to AAHomecare.CGS will be reviewing A6196 and A6212, and L1833 and L1851. The DME MAC is conducting the reviews due to data analysis that showed “significantly above expected amounts.”Surgical dressings and knee orthoses also ranked No. 5 and No. 9, respectively, in total CERT improper payment rates. The reviews will include only claim...

COLUMBIA, S.C. - Audits have started to pop up in a number of places, including more recently, from the SMRC, says Andrea Stark. “I haven't seen any posts to the SMRC website announcing new audits, but I'm starting to hear the initial murmurings from suppliers they are receiving audit requests from the SMRC that may involve vents or oxygen - indicating a respiratory related review,” said Stark, a reimbursement consultant with MiraVista. “But they're non-public audit requests so...

WASHINGTON - Performant, Medicare's RAC, has notified providers by letter that, per authorization from CMS, it will resume certain medical review activities, according to the van Halem Group.The notification says providers have an additional 30 days to submit discussion requests for review for result and initial findings letters dated Feb. 27, 2020, to March 27, 2020. It also advises providers to access the Provider Portal to review any claims pertaining to those dates.Performant most recently posted...

WASHINGTON - The Office of Medicare Hearings and Appeals has extended the eligibility requirements to participate in a Settlement Conference Facilitation to appeals filed on or prior to March 31, 2020, that are pending at the administrative law judge hearing or Medicare Appeals Council review level, AAHomecare and the van Halem Group report. CMS launched the Settlement Conference Facilitation pilot program in July 2014 as an alternate dispute resolution process designed to bring the appellant and...

ATLANTA - CGS has announced that the Jurisdiction B medical review department will begin complex post-pay service-specific reviews on back braces and test strips, according to the van Halem Group. Both reviews are the result of data analysis that indicates the allowed dollars for the two codes in Jurisdiction B are significantly above expected amounts. Each code also ranks high in the CERT Errors Top 15, with L0650 ranking No. 6 and A4253 No. 11, according to the van Halem Group. Based on earlier...

WASHINGTON - The DME MACs will resume medical reviews Aug. 17, according to a bulletin from CMS. The MACs will perform post-payment reviews of items/services provided before March 1, 2020. The Targeted Probe and Educate program will restart later. The MACs will continue to offer detailed review decisions and education as appropriate. CMS had suspended all audit activities at the start of the COVID-19 public health emergency.