Working with insurance companies is rarely simple, and when it comes to payer reviews, you may only have one chance to get things right. With payers scrutinizing claims more than ever before, urgent cares are worried about what that means for their bottom line and what they need to do to prevent rejections and denials.
This guide explains three different payer reviews — pre-payment, post-payment, and probe — along with steps to take in each situation. While there is an ascending level of concern associated with these, you should always take payer reviews seriously and address them promptly.
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 4s 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%.
Level of concern: Low
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 squander that opportunity with having to prove your practice performed the service. Rather, use the appeal to defend your coding.
Level of concern: Moderate
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.
Level of concern: High
Bottom-line: Don’t panic! 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.
You don’t have to take on a billing audit alone. Experity has performed over 400 no-obligation, free billing analyses to help urgent cares identify what’s working well and where to improve in their RCM. Get yours to not only better defend payer reviews, but also optimize your revenue.
Obviously, tightening up your billing practices can help you minimize payer reviews and be better prepared when they do occur. However, provider habit are often the reason for unusual patterns in claims data and other reasons for a review. Without the right analytics, it can be complicated to get visibility into E/M weights and other coding issues.
Furthermore, your odds of accuracy are much higher if you have help identifying potential concerns. Here are a few proactive steps you can take to improve your claims.
You are the first line of defense — you should know what’s going on at your practice, understand how to identify issues, and provide guidance/education to rectify and prevent mistakes.
This all starts with data. Your PM should provide reports that help you see what’s happening at your clinic. If you aren’t diligent about running routine reports for insights, you should start now.
If you already rely on data from your PM, but find it is still difficult to get what you need, you may be a good candidate for a business intelligence solution. This will simplify your data collection and review process – and also let you track more granular, specific details quickly.
Schedule regular internal coding audits to find inaccuracies and outliers that could indicate more education is needed. Remember, these audits will not only identify where you may be inaccurately upcoding but can also show if providers are under coding visits, lowering potential revenue.
If you’ve chosen to work with a third-party biller, they should be able to catch some unusual patterns and other discrepancies before submitting your claims. If your billing partner does not understand urgent care-specific issues and red flags, you may need to consider a new partner. If you do billing in-house, this comparison piece can help you decide if it’s time to recruit help: In-house vs Outsourced Billing in Urgent Care: Pros and Cons
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