Medical Review 2021: What is—and isn’t

This month there was a joke that the Groundhog, upon poking his head out of his burrow on February 2, determined that there was going to be another six weeks of 2020. And as we proceed into 2021 it seems that the challenges of 2020 will continue for the immediate future.


Even during--and perhaps despite--the Public Health Emergency (PHE), medical review activity has continued.


At the start of the PHE back in March 2020 most types of medical review was suspended. This included Medicare Administrative Contractor (MAC) Targeted Probe & Educate (TPE), Recovery Audit Contractor (RAC), Supplemental Medical Review Contractor (SMRC), and Comprehensive Error Rate Testing (CERT) reviews.


However, CMS in August 2020 stated “To protect the Medicare Trust Fund against inappropriate payments, Medicare Administrative Contractors (MACs) are resuming fee-for-service medical review activities...with post-payment reviews of items/services provided before March 1, 2020. The Targeted Probe and Educate program (intensive education to assess provider compliance through up to three rounds of review) will restart later...MLN Connects 8-6-20


Based on this, while general TPE reviews have not yet restarted, many agencies are seeing limited post-payment reviews for claims submitted prior to March 2020. These are single or minimal reviews but are occurring.


Currently it seems that the biggest chance for medical reviews is coming from the Unified Program Integrity Reviewer (UPIC) contractors and Medicare Advantage (MA) payers using the contractor SCIO Health Analytics (SCIO).


UPICs were exempt from the PHE medical review pause and continued throughout the suspension of other reviews. Claims that seemed to draw special attention were multiple recertifications , similar referral sources and ordering physicians, and certain diagnoses that have historically been cited for their general nature.


MA audits using SCIO for conducting the reviews seem to follow long length of service patients, certain diagnoses, and claims with therapy usage (focused on content of the required 30-day reassessments). There seems to be a substantial uptick in MA SCIO review activity, often on claims dating back several years.


These types of reviews have posed special challenges to agencies since the documentation has long been completed and filed (i.e., these are “old charts”). Any issues in the record are not able to be corrected since the final bill has been submitted.


So as 2021 proceeds it looks like it's much the same as 2020. The new no-pay RAP is the biggest change from 2020 that changes the admission process. Agencies must deal with the complications of Covid and managing PHE allowed clinical waivers (such as Telehealth, non-physician certifications, and OASIS timeliness). But while doing this they need to keep in mind that they are still subject to medical reviews and their charting needs to meet coverage requirements for all payers.


2021 is shaping up a lot like 2020...


As the Public Health Emergency (PHE) continues, the Centers for Medicare and Medicaid Services (CMS) has made some recent adjustments to their medical review activities. First was the phase-in of the Review Choice Demonstration (RCD) project for the remaining states of Florida and North Carolina. CMS just announced on October 29 that this will now continue until January 1, 2021. CMS RCD


As before, providers in these states MAY submit pre-claim review (PCR) requests as of August 31, 2020. Any claim that undergoes PCR that is submitted with a valid Unique Tracking Number (UTN) when final billed will then be excluded from further medical review. It is up to each agency how many, if any, claims they wish to put through the PCR process.


Also continuing is that if an agency chooses to submit its claims without putting them through PCR, the claim will process and pay as normal and will not undergo a 25% payment reduction. However, these MAY then be subject to later post-payment review.


Joe Osentoski BAS, RN-BC

ADR and Appeals Specialist

Gateway Home Health Coding & Consulting

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