A New Look - Medicare Administrative Contractors To Resume Fee-For-Service Medical Reviews

On March 30, 2020, CMS announced that it was stopping the majority of FFS medical reviews during the COVID-19 public health emergency (PHE). In July, CMS advised that it expected to “discontinue exercising enforcement discretion” as of August 3, 2020, regardless of the ongoing PHE, and on August 6, 2020, CMS advised that FFS medical reviews will begin August 17, 2020.

Unlike the pre-payment Targeted Probe and Educate (TPE) reviews, the FFS medical reviews will be post-payment reviews of items and services provided prior to March 1, 2020. Providers can request education, although education will not be mandatory as is required with TPE. TPE will resume at a future time. Providers’ responses to an Additional Development Request (ADR) sent by the MAC in connection with the FFS medical review must be within 45 days of the ADR. Providers facing difficulty with responding timely to the ADR due to the PHE should contact their Medicare Administrative Contractor to request an extension. Any claims denied pursuant to these FFS reviews can be appealed through the Medicare appeal process

FFS providers should get ready for an increase in audits and should pay close attention to deadlines for responding to any ADRs.