CMS: Expect return of RAC, TPE, and other audits in August

CMS is planning to restart most Medicare fee-for-service medical reviews by August 3, according to a recently released FAQ. The agency expects to resume the Targeted Probe and Educate (TPE) program, Supplemental Medical Review Contractor (SMRC) reviews, and Recovery Audit Contractor (RAC) reviews regardless of the status of the novel coronavirus (COVID-19) public health emergency (PHE).

CMS suspended most of its pre- and post-payment medical review programs at the beginning of the PHE in March. However, because states have begun to reopen and considering the importance of these reviews to CMS’ program integrity efforts, the agency does not expect to extend the enforcement discretion period.

If an organization is selected for review, it should discuss any COVID-19 related hardships it is experiencing with its MAC. Auditors are expected to apply any waivers and flexibilities that were in place on the dates of service of any claims selected for review.

Organizations should take the appropriate steps to prepare, including reviewing their audit response processes and notifying staff involved in audit response. Organizations should also continue to monitor communications from CMS for updates on the agency’s audit and review programs.