Post-PHE Medical Reviews with a PHE Extension 2022 Update

With the Public Health Emergency (PHE) ending in early 2023, many DME providers and suppliers are trying to learn what to expect. One primary concern is how the Centers for Medicare and Medicaid Services (CMS) will conduct medical reviews once the PHE ends. The good news is CMS just released additional information to help providers and suppliers navigate the upcoming post-PHE medical reviews.

Upcoming Medicare Fee-for-Service Claim Reviews

Before the start of the PHE, the CMS contractors would typically review only a small percentage of Medicare Fee-for-Service claims every year. The contractors who conduct these reviews include:

  • Medicare Administrative Contractors (MAC)
  • Recovery Audit Contractors (RAC)
  • Supplemental Medical Review Contractors (SMRC)

In order to maintain everyone’s safety, CMS allowed for some flexibility and didn’t enforce claim reviews. This included the reviews of the clinical indications for coverage with certain DME items. 

Expectations for Post-PHE Medical Reviews

Contractors will focus on claims with clinical indications of coverage (when applicable) with dates of service outside of the PHE period. Contractors will review the claims using the applicable rules that were in place during the claim’s dates of service. And good news, the CMS’s primary focus on medical reviews doesn’t include waived claims.

One Point to Note

There’s still a possibility the contractors will review DME items or services with dates of service during the PHE period. The purpose of these reviews is to address any potential concerns of fraud. This is mainly for claims that show unusual billing behaviors.

Heads Up

You might even see the HHS Office of the Inspector General performing medical reviews as necessary. 

High Possibility of a PHE Extension 

As of this article’s publishing date, the PHE is scheduled to end on January 11, 2023. The Department of Health and Human Services would have provided a 60-day notice before the end. Because that time has passed, there is a strong possibility of extension. 

Need More Information?

Read more about the Medical Review and Education Program. If you need additional information on the Medicare Fee-for-Service Compliance Programs, click here.

Thank You AAHomecare 

We appreciate all the work the team at AAHomecare continues to do for our industry, especially concerning PHE. They will continue to stay in touch with CMS to help our industry transition back to normal. 

Learn How Medbill Can Help You in 2023

Don’t miss a beat when the PHE ends. Contact us to learn how we can help with your DME billing needs.