Medical Review: Our Goal
One primary goal of the Medicare Integrity Program is to pay claims correctly and reduce the claims payment error rate as defined under the Government Performance and Results Act (GPRA). The Centers for Medicare and Medicaid Services (CMS) has a goal to reduce the Medicare fee-for-service claims payment error rate to 4.7% gross by the year 2008. In order to meet that goal, contractors like Highmark Medicare Services must ensure that they pay the right amount for covered, medically necessary, and correctly coded services rendered to eligible beneficiaries by legitimate providers.
CMS instructs contractors to use four parallel strategies to assist in meeting this goal:
- Preventing inappropriate payments through accurate and effective enrollment of providers and beneficiaries;
- Detecting program aberrancies through data analysis and on-going medical review;
- Making fair and firm medical review decisions enforcing local and national policies in accordance with Progressive Corrective Action (PCA); and
- Coordinating activities and communicating information with external partners, including other contractors, law enforcement agencies, and others.
Medical review is an essential part of the Medicare Integrity Program. Primarily, medical review processes focus on identification of aberrancies or patterns of inappropriate billing, educating providers on Medicare coverage and coding requirements, and performing medical review of claims and the supporting documentation.
How Reviews are Identified:
Under Section 1842(a)(1)(C) of the Social Security Act, contractors under contract to the Centers for Medicare and Medicaid Services are authorized to conduct “audits of the records of providers of services as may be necessary to assure that proper payments are made under this part.” Highmark Medicare Services is responsible for conducting audits of providers to ensure that Medicare claims have been billed and paid appropriately. We may review all claims submitted to Highmark Medicare Services. This includes assigned and non-assigned claims for par and non-par physicians and non-physician providers.
Contractors use data analysis as the foundation for detection of abberancies or patterns of apparent inappropriate billing, which may be potential claim payment errors. Data analysis is the comparison of claim information and other related data to identify potential errors. Various sources of information and techniques are used to identify potential errors that pose the greatest financial risk to the Medicare Program. When such abberancies or inappropriate billings are identified, additional measures are taken to verify and add context to the data. The results of that additional analysis determine the type and level of corrective action that will be taken by the Medical Review Department.
Need for Corrective Actions:
For medical review purposes, once a potential problem is identified through data analysis, a probe review (sample claim review) is done to understand the nature and extent of the problem. As the result of the probe review findings, subsequent corrective actions may be needed. A variety of corrective actions, ranging from educational interventions to extensive prepayment or post payment claim reviews, may be necessary in order to correct inappropriate billings. Highmark Medicare Services uses the administrative action(s) that is commensurate with the magnitude of the problem identified. Reviews may be conducted on a prepayment or post payment basis; however, Highmark Medicare Services’s current emphasis is on prepayment medical review. At any time during the course of a review, if evidence of fraud is detected, a referral will be made to the appropriate entity for further review/development.
Based on our review of medical records and other supporting documentation, an assessment of the problem will be completed. This will result in the classification of the problem as “minor”, “moderate”, or “major” and initiate additional administrative measures. Categories are determined by error rate, history of errors, and dollars involved. In addition, mitigating and aggravating circumstances are considered. Examples include: self-disclosed audits conducted by the provider, voluntary disclosures of a problem by the provider, previous educational efforts, repeated identification on data analysis reports, beneficiary complaints, history of billing problems/concerns, adverse findings from previous probes/reviews and quality issues, or quality of care concerns.
Education is the key element in PCA:
For a minor problem, MR will educate the provider on appropriate coverage, coding, and billing procedures and will pursue recoupment of any claims paid in error. Educational contacts will be made through educational letters and/or telephone conferences. MR may conduct further analysis or another probe review at a later date to ensure the problem was corrected.
For a moderate problem, MR will educate the provider on appropriate coverage, coding and billing procedures, and will pursue recoupment of any claims paid in error. Educational contacts will be made through educational letters and/or telephone conferences. Additionally, MR will initiate some level of subsequent corrective action (e.g., reprobe, prepayment provider review) until the provider has demonstrated correction of his/her billing procedures.
For a major problem, MR will educate the provider on appropriate coverage, coding and billing procedures, will pursue recoupment of any claim paid in error, and will initiate prompt, stringent administrative action (i.e., any combination of reprobe, prepayment provider review, consent/SVRS cases, payment suspension and/or referral to Penn-BISC if and when appropriate). Educational contacts will be made through educational letters and/or telephone conferences. Additionally, the provider will have the opportunity for a face-to-face meeting.
Note: PCA requirements do NOT apply when fraud development is initiated.
Appeals
If a provider disagrees with a MR determination, the provider may request an independent re-examination of a claim(s) consistent with the CMS appeal process. A review may be requested if the provider is dissatisfied with the amount Medicare paid on the claim(s), or if the claim was denied because Medicare determined the service(s) was not reasonable or necessary or not allowable due to coverage guidelines.
Subsequent progressive actions (i.e., prepayment provider review) may NOT be pended or placed on hold for the results of an appeal and/or hearing decision from a previous case.
Physician Obligations
Participation in the Medicare program requires that physicians abide by the following obligations when submitting claims for payment:
1. Bill Medicare for only reasonable and necessary medical services
[42 U.S.C. § 1395y(a)(1)(A)];
2. Not make false statements or misrepresentations of material facts concerning requests for payment under Medicare [42 U.S.C. §§ 1320a-7b(a)(1)(2), 1320a-7a; 42 CFR § 1001.101(a)(1)];
3. Provide economical medical services and then, only when medically necessary [42 U.S.C. § 1320c-5(a)(1)];
4. Provide evidence that the service given is medically necessary
[42 U.S.C. § 1320c-5(a)(3)];
5. Assure that such services are not substantially in excess of the needs of such patients [42 U.S.C. § 1320a-7(b)(6)(8)];
6. Certify when presenting a claim that the service provided is medically necessary [42 U.S.C. § 1395n(a)(2)(8)]; and
7. Not submit or cause to be submitted to the Medicare Program bills or requests for payment substantially in excess of the physician’s usual charges for the same treatment or services [42 U.S.C. § 1320a-7(b)(6)(A); 42 CFR § 1001.101(a) (2); CMS Carrier Manual § 14006.1].
Types of Reviews: (hyper link to MR Glossary for each definition)
Prepayment provider-specific review