CMS recognizes that it is important for stakeholders to understand how CMS anticipates performing medical review after the Public Health Emergency (PHE) has ended. Below is an FAQ that addresses how our review contractors (Medicare Administrative Contractors (MACs), Recovery Audit Contractors (RACs) and the Supplemental Medical Review Contractor (SMRC)) plan to conduct medical reviews post PHE.
Q. At the end of the Public Health Emergency (PHE) how will CMS’ review contractors conduct medical reviews for claims billed during the PHE based on approved waivers or flexibilities?
A. CMS contractors (MACs, RACs, and SMRC) review a very small percentage of Medicare Fee-for-Service claims each year. During the PHE, flexibilities were applied across claim types. For certain DME items, this included the non-enforcement of clinical indications for coverage. Since clinical indications for coverage were not enforced for certain DME items provided during the PHE, once the PHE ends CMS plans to primarily focus reviews on claims with dates of service outside of the PHE, for which clinical indications of coverage are applicable. We note that we may still review these DME items, as well as other items or services rendered during the PHE, if needed to address aberrant billing behaviors or potential fraud. The HHS-Office of the Inspector General may perform reviews as well. All claims will be reviewed using the applicable rules in place at the time for the claim dates of service.
The Medicare Fee-for-Service Compliance programs prevent, reduce, and measure improper payments in FFS Medicare through medical review. We provide a number of programs to educate and support Medicare providers in understanding and applying Medicare FFS policies while reducing provider burden.
Medical Review & Education
Medical reviews involve the collection and clinical review of medical records and related information to ensure that payment is made only for services that meet all Medicare coverage, coding, billing, and medical necessity requirements.
- CMS's Targeted Probe and Educate (TPE) program is designed to help providers and suppliers reduce claim denials and appeals through one-on-one help.
- Learn more about our Medical Review and Education programs
Recovery Auditing
Medicare Fee-for-Service (FFS) Recovery Audit Contractors (RACs) review claims on a post-payment basis. The RACs detect and correct past improper payments so that CMS can implement actions that will prevent future improper payments in all 50 states.
Read more about the Medicare FFS Recovery Audit Program.
Prior Authorization & Pre-Claim Review
Through prior authorization and pre-claim review initiatives, CMS helps ensure compliance with Medicare rules.
- Learn more about how Prior Authorization and Pre-Claim Review programs work
- Get information and resources about current initiatives
- Understand previous initiatives and their results
Prior Authorization Lookup Service
Use the Prior Authorization Lookup Service to determine if Medicare Fee-for-Service requires Prior Authorization for certain items or services in your state.
Outreach & Education
Annual Wellness Visit (AWV) Video
The AWV video provides health care professionals with guidance to understand expectations and requirements when submitting AWV documentation for Medicare beneficiaries.
For more information about health risk assessments and other AWV components, read this MLN Matters® booklet (PDF).
Improving the Documentation of Chiropractic Services
In this video, learn more about documentation requirements for chiropractors to help reduce the improper payment rate for chiropractic services, which have the highest rate of improper payments for Medicare Part B services.
Program to Evaluate Payment Patterns Electronic Report – PEPPER
PEPPER provides provider-specific Medicare data for services vulnerable to improper payments. It can be used as a guide for auditing and monitoring efforts to help providers identify and prevent payment errors. Learn more about PEPPER.
Comparative Billing Report – CBR
A CBR provides data on Medicare billing trends, allowing a health care provider to compare their billing practices to peers in the same state and across the nation. A CBR educates providers about Medicare’s coverage, coding, and billing rules and acts as a self-audit tool for providers. Get information, training, and support related to CBRs.
Provider Compliance Tips
Provider Compliance Tips are quick reference fact sheets to educate and provide high-level guidance to providers about claim denial issues and provide claim submission and documentation guidance. The tips cover Part A, B, and DME services with high Medicare improper payment rates. Access these tips and more on the Medicare Learning Network.
Improving Provider Experience
Electronic Submission of Medical Documentation – esMD
The esMD system enables providers to send medical documentation to review contractors electronically. Using the esMD system decreases costs, increases efficiency, helps improve payment turnaround time, and reduces the administrative burden of medical documentation requests and responses. Learn more about esMD.
Electronic Medical Documentation Interoperability – EMDI
EMDI engages key healthcare stakeholders in the advancement of interoperability of electronic medical records between hospitals, physicians, labs, and vendors. The primary focus of EMDI is Provider-to-Provider communications using standards similar to esMD. Learn more about EMDI.
Simplifying Documentation Requirements
Medicare is simplifying documentation requirements so that you spend less time on paperwork, allowing you to focus more on your patients and less on confusing and time-consuming claims documentation. Learn about what we are doing.
Clinical Templates
These templates and suggested clinical data elements (CDEs) are intended to help reduce the risk of claim denials and ensure that medical record documentation is more complete. Download and learn more about the clinical templates and CDEs.
Documentation Requirement Lookup Service Initiative
CMS is collaborating with ongoing industry efforts to streamline workflow access to coverage requirements, starting with developing a prototype Medicare Fee for Service (FFS) Documentation Requirement Lookup Service (DRLS).