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Medical Review NHIC, Corp.’s (NHIC) Medical Review Strategy has been developed to achieve the goal of the Centers for Medicare & Medicaid Services (CMS) Medical Review (MR) program to assure that the Medicare program makes payments only for covered, correctly coded services and to reduce payment error rate. Moreover, our strategy is to use education, proactively and retroactively, as the primary corrective action whenever possible. Note: Should you have landed here as a result of a search engine (or other) link, be advised that these files contain material which is copyrighted by the American Medical Association (AMA). You are forbidden to download the files unless you read, agree to and abide by the provisions of the copyright statement. Read the copyright statement now (you will be linked back to here).
Goal of the Medical Review (MR) Program The goal of the Medical Review (MR) program is to reduce payment error by identifying and addressing billing errors concerning coverage and coding made by providers. To achieve this goal, NHIC will perform the following:
The NHIC Medical Review strategy emphasizes prevention of errors in order to minimize recoupment efforts. The NHIC MR Strategy seeks clinical and statistical approaches to identify incorrect billing patterns and contribute to reducing incorrect billing. The MR Strategy includes an expanded aggressive provider education effort supported by ongoing multidisciplinary workgroups to identify educational opportunities. This expanded provider education focus is supported by an innovative approach to identify incorrect billing patterns. NHIC will continue detection of incorrect billing patterns identified through various sources including data analysis of claim denial/reversal statistics, overutilization, and unusual frequencies of accepted codes. MR Functions and Activities The primary functions of MR operations are described below: Pre-Payment Medical Review The NHIC Prepayment Medical Review staff performs a variety of functions. Staff members are responsible for adjudication of complex claims that require clinical expertise in determining medical necessity. The primary function of the pre-payment medical review team is to ensure that services suspended for review are both reasonable and necessary. The prepayment staff is also a medical resource to other NHIC operational areas. Medical staff assists with issues relating to policy clarification, interpretation of medical necessity issues not covered by local or national policies, and contributes in the development of claims processing guidelines. Selected Claim/Service Review The prepayment staff also initiates claims review for specific claims and services either at random or selected samples. The MR staff will request supporting MR documentation, and upon its receipt will evaluate and determine if services were reported and documented appropriately. Provider Prepayment Review MR prepayment staff also conducts claim reviews for providers or groups with identified billing problems that require monitoring prior to reimbursement. Providers may be placed on a prepayment review for a specific service or all services reported to Medicare. The level of review is dependent upon the nature of the problem identified. Medical Review staff evaluates the necessary claims/services and supporting documentation to determine if services are being reported appropriately. MR staff monitors trends and changes to billing and documentation patterns and communicates review results to MR analysts or Provider Education and Outreach when feedback to a provider is required. Post-payment Medical Review Post-payment medical review consists of validation of potential billing errors or claims payment errors after claims have been adjudicated by NHIC. There are two specific areas of post-payment review: Progressive Corrective Action (PCA) reviews and Statistical Sampling for Overpayment Estimation Reviews (SSR). Progressive Corrective Action (PCA) The Progressive Corrective Action Program was initiated by CMS in October 2000. The goal of the PCA program is to target incorrect billing patterns, educate providers and correct issues identified in order to improve the accuracy of Medicare payments. CMS requires contractors to conduct a “probe review “ of 20-40 claims to establish if claims are being billed in error. NHIC will not exceed 40 claims when reviewing for a potential billing problem to ensure providers will not experience any overdue administrative burden. Data analysis techniques are used to determine if a pattern of code utilization, claim submission or payment indicates potential problems. Probe reviews may also be identified through referrals from the CMS, the Office of Inspector General, contractor alerts or NHIC operational areas. Steps involved in the Probe Review Process
Statistical Sampling for Overpayment Estimation Reviews (SSR) NHIC conducts Statistical Sampling for Overpayment Estimation Reviews (SSR) reviews on physicians' services to evaluate provider claims who appear to warrant an in depth review to: 1) identify and validate problems regarding any unusual practice patterns, 2) verify that reimbursements are made only for those services which are considered to be medically necessary, 3) rule out over utilization or abuse of the Medicare Program. The major steps in conducting statistical sampling are: (1) Selecting the physician or supplier; (2) Selecting the period to be reviewed; (3) Defining the universe, the sampling unit, and the sampling frame; (4) Designing the sampling plan and selecting the sample; (5) Reviewing each of the claims (or portions thereof), and determining if there was an overpayment, or, for administrative reviews, an underpayment; and, as applicable, (6) Estimating the overpayment. Statistical Sampling for Overpayment Estimation Reviews (SSR) calculates and projects the amount of overpayments made on Part B claims. Statistical sampling is used to estimate overpayments made to physicians and suppliers as defined by CMS. CMS directs contractors to use statistical sampling to conserve resources of the Medicare program when reviews are performed on a large universe of claims. CMS states that in most cases it would not be administratively feasible, given the volume of records involved and the cost of retrieving and reviewing all the beneficiary records, for contractors to examine all individual claims for the period in question. Corrective Action Plans CMS advises contractors to initiate specific corrective actions based on the severity of the issue(s) identified. Upon completion of the probe review a provider corrective action plan will be created, communicated and implemented. CMS expects providers to evaluate probe and SSR findings and implement changes to correct issues identified. The following describes the types of corrective actions that could be initiated as a result of a probe review:
Corrective Action Plan Monitoring NHIC will conduct periodic monitoring to evaluate providers who have been educated or placed on prepayment review as a result of a probe review a Statistical Sampling for Overpayment Estimation review. The purpose of follow up monitoring is to determine if corrective actions have been initiated to address issues identified during the probe review. Providers under prepayment claims review receive written notification of their progress which includes additional feedback and education. Providers under prepayment review are encouraged to review Remittance Advices carefully and contact Medicare customer service with questions regarding specific claim determinations. Providers are removed from prepayment review when follow up analysis demonstrates compliance with Medicare coverage and coding regulations. Educational News Articles NHIC, Corp.’s (NHIC) Medical Review Strategy has been developed to achieve the goal of the Centers for Medicare & Medicaid Services (CMS) Medical Review (MR) program to assure that the Medicare program makes payments only for covered, correctly coded services and to reduce payment error rate. Moreover, our strategy is to use education, proactively and retroactively, as the primary corrective action whenever possible. For more information, please refer to theEducational Articles. 02/07/2008 |
