The goal ofGHI Medicare’s MR program is to assist the Centers for Medicare & Medicaid Services (CMS) in reducing the Medicare fee-for-service paid claims error rate by identifying and addressing program vulnerabilities concerning coverage and coding. This is accomplished through analysis of data, including CERT program data, and evaluation of other available information.

Data analysis is the tool for identifying, prioritizing and correcting potential claim payment problem areas and drives GHI Medicare’s MR/LPET activities. Data analysis identifies trends, patterns, utilization rates and aberrancies from national or local norms by claim characteristics, e.g., diagnoses, procedures, providers or beneficiaries, individually or in the aggregate. Data analysis is an integrated, on-going component of GHI Medicare’s MR program. The Carrier Medical Director oversees the problem identification process and has final sign off on all HCPCS codes and providers selected for medical review.

PCA is the approach to Medical Review followed by Medicare carriers to ensure that medical review activities are targeted at identified problem areas. Hypotheses formulated during data analysis are initially tested by probe reviews. A small probe sample of claims (usually 20-40) is selected for postpayment review on those providers who have unusual or aberrant billing patterns. The goals of the probe review are to identify the nature of the problem, determine the extent of the problem and formulate strategies to prevent future occurrence. 

 

Providers selected for probe reviews are notified in writing of the review and the subsequent review findings. MR clinicians (i.e. Registered Nurses, Medical Consultants) review medical records received during the probe review period. GHI Medicare’s Local Coverage Determinations are the basis for determining the appropriateness of the medical documentation.

 

Following a postpayment probe review, a provider with a low error rate will be educated on the applicable policies, either by conference call or face-to-face meeting, to discuss policy requirements. Providers with a high error rate, in addition to receiving one-on-one education, will be subjected to prepayment review for the HCPCS codes with high error rates.   These providers will receive a written explanation describing the types of errors uncovered during the probe review and a detailed description of Local Coverage Policy pertaining to the services reviewed. 

 

Providers with high error rates will be notified in writing that prepayment review will be undertaken for a three to six month period until the provider establishes an understanding of the policies governing the codes and is billing appropriately. The goal is to reduce and eventually eliminate the error rate for these providers. Providers who establish a satisfactory error rate within this timeframe, or upon review of a significant sample of claims (usually 100), receive a letter advising them that they are no longer subject to review. Additional education for future billings is included.

 

Prepayment edits are put in place to prevent payment for non-covered and/or incorrectly coded services and to select targeted claims for review prior to payment. Prepayment edits are carefully focused to ensure review of only those claims with a high probability of being denied when subjected to medical review, thereby reducing provider burdens and increasing the efficiency of MR activities. 

 

Automated edits are decisions made at the system level using available electronic information without the intervention of carrier personnel. These edits may be implemented only if there is a clear policy that serves as the basis for denial. Non-automated types of prepayment edits result in a claim being excepted from claims processing for review of medical record documentation. The specific medical record information necessary for review is requested from the provider by an ADR (additional documentation request) letter.

 

Development and retention of prepayment edits is based on data analysis. GHI Medicare assesses all prepayment edits quarterly to determine their effectiveness. The Carrier Medical Director is consulted on any changes to edits associated with local or national policy.

The overall goal of GHI Medicare's LPET program is to reduce the claims error rate as measured by the CERT program through the use of educational interventions targeted at procedures and providers responsible for the major components of the error rate. These interventions are performed by clinicians or through written material developed with significant clinical involvement.

 

Provider education is directly linked to Medical Review (MR). The goal of GHI Medicare’s provider education efforts is to reduce the error rate by ensuring that the provider community fully understands the regulations, policies and documentation requirements associated with all services that they are billing. Problem areas uncovered during MR are the main force driving LPET. Additionally, information provided by the CERT contractor is utilized to formulate interventions which have the greatest likelihood of improving the error rate. 

 

LPET is also used to address new local medical review policies or at the request of a provider or provider group. LPET may be in writing, by telephone conference or face-to-face meeting. In some situations, it may involve addressing a wide range of providers, smaller groups of providers of a given specialty or who share a common problem or individual providers. LPET is designed to address specific problems or regulations with a defined goal in mind. All LPET activities are determined by careful data analysis with significant input from GHI Medicare’s Medical Director and the clinical staff.

 

The effectiveness of LPET educational activities is measured by examining the billings of the targeted providers following education and training. All interventions have a measurable objective which is tested post-intervention to insure that the intended outcome is achieved. Surveys are used to ensure that participants in LPET activities have received useful education and to plan future actions.