Providers generally remain on prepayment review until their average rate of claims approval reaches a sufficiently high percentage, which is usually 80%.ĬMS has directed its contractors to consider excluding physicians and other providers from Medicare and Medicaid if they have been on prepayment review for extended periods of time without correcting their “inappropriate behavior.” Exclusion from participation in Federal healthcare programs typically leads to other adverse consequences, such as loss of hospital privileges and being dropped from managed care networks. The submitted claims are then either approved or denied based on the manual review. The records and documentation are then manually reviewed by nurses and other licensed practitioners. Rather than paying these providers upon the submission of claims, the contractors require the providers to submit medical records and other documentation to support the claims. Once providers re-establish the practice of billing correctly, prepayment review ends at the discretion of the contractor.Ī Medicare contractor will place a provider on prepayment review if they suspect the provider is billing the Medicare program inappropriately. If this happens, a percentage of the provider’s claims undergo MR before the MAC authorizes payment. A MAC can place a provider with identified problems submitting correct claims on prepayment review. CMS, MACs, and other claim review contractors target MR activities at identified problem areas appropriate for the severity of the problem. These contractors identify suspected billing problems through error rates produced by the Comprehensive Error Rate Testing (CERT) Program, vulnerabilities identified through the Recovery Audit Program, analysis of claims data, and evaluation of other information, such as complaints. MRs are performed by MACs, Zone Program Integrity Contractors (ZPICs), and Supplemental Medical Review Contractors (SMRCs). MACs analyze whether the procedure on the submitted claim complies with MUE policy. MUEs and NCCIs are automated prepayment edits. MACs also perform MUEs, which were created to reduce the paid claim error rate for Medicare claims. NCCI edits prevent improper payments when incorrect code combinations are reported. CMS developed the NCCI to promote national correct coding methods and to control improper coding that leads to inappropriate payment in Medicare Part B claims. NCCI Edits are performed by Medicare Audit Contractors (MACs). Prepayment Claim Review Programs apply to the National Correct Coding Initiative (NCCI), Medically Unlikely Edits (MUEs), and Medical Review (MR). The demonstration focused on eleven states: California, Florida, Illinois, Louisiana, Michigan, Missouri, New York, North Carolina, Ohio, Pennsylvania, and Texas. In 2012, CMS introduced the Recovery Audit Prepayment Review Demonstration, which allows Recovery Auditors (RACs) to conduct prepayment reviews on certain types of claims that historically result in high rates of improper Medicare payments. The Prepayment Review Process Comes to Life The key is to truly understand the prepayment review process and what you can do to minimize any potential problems. Moreover, health care providers in prepayment review face expensive complications, including possible exclusion from Federal healthcare programs, if the problems which caused them to be subject to prepayment review go uncorrected. Unlike the traditional postpayment review process, if a health care provider is placed under prepayment review, there is very little you can do other try to identify the nature of deficiencies noted so that remedial action can be taken. In this process, government contractors will review a claim for problems before the claim may be paid. One of the most recent trends involves pre-payment review of claims. The Centers for Medicare & Medicaid (CMS) has instituted several methods to help combat the increase in waste, fraud, and abuse in the federal and state health care programs.
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