CMS Announces the Resumption of Medicare Audits and New Implementation Date for Medicare Prior Authorization


The Centers for Medicare and Medicaid Services (CMS) recently updated its COVID-19 Reduction of Provider Burden Frequently Asked Questions (FAQ) document to provide updates on the resumption of Medicare audit activity and revised implementation dates for Medicare prior authorization of six lower limb prosthesis codes.

Resumption of Medicare Audits

The FAQ was updated to indicate that CMS has authorized Medicare contractors (e.g. DME MACs, RACS, SMRCs, etc.) to once again perform pre-payment and post-payment audits as part of their medical review responsibilities.  CMS had suspended most audits as of March 30, 2020 due to the COVID-19 Public Health Emergency (PHE).  In the updated FAQ, CMS indicates that due to the “importance of medical review activities to CMS’ program integrity efforts, CMS expects to discontinue exercising enforcement discretion beginning on August 3, 2020, regardless of the status of the public health emergency.”  CMS indicates that if individual providers are selected for medical review believe that responding to a request for documentation will create a hardship situation, they should discuss response options with the contractor performing the review.

It is important to note that CMS authorized the reinstatement of all Medicare audits, not just audits of orthotic and prosthetic claims.

The timing of the resumption of audit activity is surprising considering that the PHE remains in effect and AOPA will be communicating our concern to CMS about the burdens that renewed audit activity will place on providers that are already operating under challenging circumstances.

Update on Medicare Prior Authorization

The updated FAQ also included new implementation dates for the Medicare Prior Authorization program for the six lower limb prosthesis codes (L5856, L5857, L5858, L5973, L5980, and L5987) that had their original implementation delayed due to the COVID-19 PHE.  CMS announced that Medicare prior authorization for the six codes will begin in the four states previously selected for the initial roll out (PA, MI, TX, and CA) on September 1, 2020 and will be implemented nationally on December 1, 2020.

AOPA has developed resources to assist members to understand how the prior authorization process will work and what to expect from it.  These resources, including live and on demand education opportunities will be made available to AOPA members soon.

View the updated CMS FAQ document.

Questions regarding these issues may be directed to Joe McTernan at jmcternan@AOPAnet.org or Devon Bernard at dbernard@AOPAnet.org.