Medical Review Resumption: What is—and isn’t

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.


Other Reviews Are Resuming: And Not


At the start of the PHE, most types of medical review were also 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.


Then, CMS posted that “To protect the Medicare Trust Fund against inappropriate payments, Medicare Administrative Contractors (MACs) are resuming fee-for-service medical review activities. Beginning August 17, the MACs are resuming 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. The MACs will continue to offer detailed review decisions and education as appropriate.” MLN Connects 8-6-20


Each of the home health MACs have posted this information. Note that general TPE reviews are NOT resuming yet—only selected post-payment reviews will be generated, and these will encompass service from BEFORE the PHE was initiated.


So that means most medical review has not actually restarted, although it could be.


This leaves as the current, biggest, and most problematical chance of medical reviews the Unified Program Integrity Reviewer (UPIC) contractors. UPICs were exempt from the PHE medical review pause, can still operate in RCD demonstration states, and continue to be active as agency billing patterns shift due to the implementation of the Patient-Driven Groupings Model (PDGM) and how Covid-19 care may have changed billing.


The trail leading out of the woods for medical review is currently marked by breadcrumbs. CMS is allowing review to occur, and it is up to each contractor how much and how this will be applied. Agencies are still at risk for UPIC audits and are now at some risk for a MAC post-payment review of pre-PHE claims. Note that these types of reviews have historically posed specific challenges to agencies since the documentation is completed and filed (i.e., “old charts”), any technical billing deficiencies are not able to be corrected, and an adverse result may result in the dreaded extrapolation of the denial rate to the universe of claims.


So at present, in addition to dealing the complications of Covid, managing the PHE allowed clinical waivers (such as telehealth, non-physician certifications, and OASIS timeliness), agencies need to be aware that they are still subject to medical reviews and their charting needs to be up to speed on regulatory compliance.

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