The Centers for Medicare & Medicaid Services (CMS) published the much-anticipated Frequently Asked Questions (FAQ) that provides some directions on the ending of the COVID-19 Public Health Emergency (PHE). In its Frequently Asked Questions: CMS Waivers, Flexibilities, and the End of the COVID-19 Public Health Emergency, CMS posted 25 questions and answers and includes two specific to durable medical equipment (DME) supplies and one for continuous glucose monitors.
"Today’s announcement from CMS represents a mixed bag for the Medicaid program," said Damon Terzaghi, National Association for Home Care & Hospice's Medicaid director. "We are heartened and excited to see that CMS is addressing issues related to waiting lists for home- and community-based services and delays in access to care, increasing transparency around provider payment rates and managed care contracting practices and requiring states to provide more justification around their payment rate structures. All of these changes will help Medicaid beneficiaries and will help promote better access to community-based services.
However, Terzaghi said that NAHC is concerned that CMS is not addressing the state payment rates for home- and community-based services, "and instead is creating a new bureaucratic analysis that may or may not ever impact the wages of workers."
"We are further concerned that CMS has decided to forego ensuring adequate state payments in favor of applying an arbitrary requirement to pass through a proportion of the rates to direct care workers," Terzaghi said. "This policy cannot be effective without consideration of the actual payment rates or the substantial administrative requirements that Federal and state regulations place on providers.”
The DME-related questions and answers can be found on pages six to seven. Below are highlights:
At the end of the PHE, how will CMS’ review contractors conduct medical reviews for claims billed during the PHE based on approved waivers or flexibilities?
Once the PHE ends, CMS will primarily focus DME 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.
What does this mean for medical review of DME supplies or ongoing DME rental claims?
We plan to primarily focus our medical reviews on claims with initial dates of service after the COVID-19 PHE. We may still review these DME items, as well as other items or services rendered during the COVID19 PHE, if needed to address aberrant billing behaviors or potential fraud.
Since Continuous Glucose Monitors (CGMs) and related supplies require a face-to-face follow up within six months, how will CMS review contractors conduct medical review for CGMs that were initially obtained during or prior to the PHE?
When evaluating for compliance with the face-to-face requirement, the Medicare Administrative Contractors, Supplemental Medical Review Contractors, and the Recovery Audit Contractors will generally focus on CGM claims with dates of service six months beyond the end of the PHE to ensure the treating practitioner had an in-person visit or a Medicare-allowed telehealth visit with the beneficiary.
AAHomecare said it received confirmation from CMS that this is the only FAQ it will be publishing regarding the ending of the PHE for now. Earlier this year, CMS announced the CR modifier will no longer be accepted once the PHE is over.
"We have communicated concerns with this direction to CMS and DME MACs and have heard that the Agency is working on a solution that is anticipated to be released prior to the May 11 ending of the PHE," said AAHomecare in a released statement.
