Insurance plans are scrutinizing claims more than ever before. Common questions from our clients are: What does this mean? What should I do? Should I be worried?
Generally, there are three types of payer reviews: pre-payment, post-payment, and probe. The first step is to figure out what type of review it is. What you do and how you handle the review is dependent on that information.
Should you be concerned? Always. Payer reviews need to be taken seriously and addressed properly. The level of concern is different for each one.
Pre-payment reviews occur when your practice’s claim data is analyzed by the payer and a provider has been identified as an outlier. For example, Dr. Jones is billing more level 4’s than other providers of the same specialty in your area. Practices are notified by letter stating which provider and which codes will require a review prior to adjudication of the claim with the date the pre-payment review takes effect. Claims for the provider with codes under review require the medical record be included at the time of initial claim submission. Failure to submit the medical records will result in a claim denial and further delay in payment.
Payers review the medical record and either adjudicate the claim if they agree with the coding or deny if they disagree with the coding. Often, a practice will receive detailed letters as to why the reviewer did not agree with the coding. Resources for education may be included.
The payer will take the practice off pre-payment review when the payer has received a specific volume of claims with a specific threshold of accuracy. For example, the practice must submit 500 claims with an accuracy threshold of 95%.
What should I do?
If you have been on a pre-payment review for months, reach out to the payer to see what can be done. The practice may need to change their behavior to see better results. This doesn’t necessarily mean lower your levels, rather you may need to improve your Provider documentation.
Post-payment reviews are routine actions by a payer. Medicare or Medicaid managed care products are required to do a review of claims for the Centers for Medicare & Medicaid Services (CMS) or your state Medicaid program to verify the payer is adjudicating the claims correctly. Dates of service will fall in the prior year or even earlier. The payer may ask for monies back if they conclude the coding was incorrect. For government payers, the amount may be extrapolated to your entire volume of claims for that payer resulting in large refund requests.
Post-payment reviews come in the form of a letter with a listing of claims for which the practice must submit records. Pay attention to the deadline in the letter. Failure to provide documentation will result in the payer requesting their payment back. A payer may give you only one appeal opportunity so it’s better not to use that with having to prove your practice performed the service. Rather, you want to use the appeal to defend your coding.
What should I do?
Probe reviews happen when a payer notices an unusual pattern in your claims data. The letter you receive will look similar to a post-payment review letter. The dates of service will be current, however. The letter may even say it is a probe review. Usually, these are provider, not practice, specific.
What should I do?
Bottom line, don’t panic but take these reviews seriously. Be organized and perform your own review focused on defending your coding where applicable and creating a learning opportunity for provider documentation and coding/billing processes going forward. Be prepared to respectfully advocate for your practice.
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