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Although Audits Restart Aug. 3, CMS Will Roll Them Out in Stages; TPE Is On Ice for Now

Although CMS’s website says it’s resuming Medicare audits Aug. 3, this will happen in stages. Hospitals and other providers won’t be hit with a flurry of documentation requests at the same time from CMS medical reviewers and program integrity contractors, and Targeted Probe and Educate is on hold for now, a CMS spokesperson said.

The perception that an audit blitz was imminent came from answers to frequently asked questions (FAQ) on provider burden relief,[1] which said CMS expected to “discontinue exercising enforcement discretion beginning on August 3.” But CMS has explained that it won’t happen all at once.

“Please know that the posted FAQ documents provided a high-level overview to participating health care providers,” a spokesperson said. “CMS will restart its prior authorization processes on August 3, 2020. After that, medical review will begin with the Medicare Administrative Contractors, followed by reviews by the Supplemental Medical Review Contractor (SMRC) and the Recovery Audit Program Contractor (RAC). To ensure provider burden is adequately addressed, the MACs will conduct post payment review. This will allow for extensions as needed. CMS will determine when it may be appropriate to begin Targeted Probe and Educate (TPE), which typically consists of prepayment review. These combined efforts are focused at lowering improper payment rates and increasing operational efficiencies. CMS is committed to resuming these program integrity activities while not negatively impacting provider burden.”

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