CMS: Audits Will Focus on Post-PHE Claims Unless Fraud Is Suspected

In an April 27 update to its guidance on waivers, flexibilities and the end of the COVID-19 public health emergency (PHE), CMS said its auditors will concentrate mostly on claims with dates of services after the end of the PHE unless there are signs of abnormal billing behavior or fraud.[1] The auditors are Medicare administrative contractors, recovery audit contractors and supplemental medical review contractors.

“Once the PHE ends, CMS will primarily focus DME [durable medical equipment] medical reviews on claims with dates of service post-PHE, for which clinical coverage requirements apply. We note that we may still review the claims for certain DME items, as well as other items or services furnished during the PHE, if needed to address aberrant billing behaviors or potential fraud,” CMS said in answers to frequently asked questions (FAQs). “If this were to occur, the appropriate review contractor website would be updated with the review topic.”

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