Skip to Main Content

Print | Bookmark | Email | Font Size: + | –

Ask the Contractor Teleconference (ACT) Medical Review Postpayment Process Questions and Answers

September 29, 2020

Click on a question to expand or Show All / Close All

  1. Can you please tell what is the status of the targeted probe and educate program? Will it resume and will it pick up where it stopped?

    • We are waiting on instructions from CMS and will share this information when it is available.

  2. Will they pick up where they left off meaning if you were in a round 2, will the same NPI HCPC pick up again in round 2? Or will new NPIs and HCPCS be selected?

    • We are waiting on instructions from CMS

  3. How many years can the CMS/RAC complete monthly Medicare A postpayment reviews?
  4. Are you aware of records requests from SIU – Screening Investigation Unit?

    • The MACs are not informed when a request is made from a SIU,

      The Screening Investigation Unit (SIU) is part of the compliance division of most major insurance companies. Each state has an administrative code generated in the legislature that gives the SIU its marching orders. This administrative code outlines the responsibilities, rights, and duties of the SIU in that state. SIUs are monitored by the U.S. Department of Health & Human Services (HHS) Office of Inspector General (OIG). The state inspector general works with the SIU to investigate allegations of fraud, waste, and abuse (FWA). Fraud is submitting documentation or claims intentionally to gain benefits to which a person or entity is not entitled. Waste is the overutilization of services or other practices that result in unnecessary costs. Abuse is seeking payment for items or services for which there is no legal entitlement).

      Examples of FWA include:

      • Medical identity theft (using another person's medical identity to obtain healthcare goods, services, or funds not otherwise entitled to)
      • Theft of provider identifiers (prescription pads)
      • Claims intentionally sent in for a patient using another patient's identity
      • Billing for services, supplies, or tests not medically necessary
      • Billing for durable medical equipment items not furnished
      • A well visit at the same time as a sick visit, without proper documentation
      • Billing for a higher level of service than the documentation supports (upcoding)
      • Billing for a power device such as a wheelchair when a manual device is provided
      • Procedures or services commonly performed together, but billed separately to generate higher payment (unbundling) by improper use of modifiers
      • Anti-kickback statute violations
      • Stark Law violations

      Methods to detect FWA vary, but the first step in detection is usually a report from a concerned party, self-disclosure from a provider, or a result of data mining. The first two are rare, and often result from possible identity theft or an internal audit. In such cases, an SIU may perform a preliminary investigation and, if appropriate, will refer to the OIG for the state.

      Data mining most often is used in retrospective reviews and involves pulling a data report from internal sources to identify areas of concern, trends, or outliers for review. This is usually when a letter is generated requesting records for review.

      Respond Properly to a Records Request

      If you receive a records request from an SIU, open it immediately and direct it to the appropriate person. This can either be the office manager, the physician, or in larger practices, the manager/supervisor of the medical records department. If someone other than the office manager or physician is responsible for processing record requests, the request should be reviewed with the office manager or physician prior to releasing the records. The reason is the physician is ultimately responsible for what is in the record and should review its contents before it's sent to the SIU.  

      Note the Due Date

      Don't ignore the request, assuming it will go away. The consequences of not complying with the request can include recoupment of money, prospective review of future claims, referral to the OIG, and/or removal from the panel of approved providers for the health plan.

      Communication is Crucial

      If the provider disagrees with the request, has concerns about the request, or has questions, it's best to reach out to the health plan SIU. This can be done through the provider representative assigned to the doctor by the health plan, or by reaching out directly to the manager of the SIU.

      Provide Only the Records Requested

      Sending records not included in the request can be a HIPAA violation, and may slow the review process. The request letter will include instructions about submitting the records. The simplest way is to make copies of the requested records and mail them certified, with a return receipt requested. Depending on the number of records requested, you may transfer the records to a CD or external hard drive, sent by certified mail. Be sure to password protect the information, and send the password by separate communication. You may fax records only if the requesting organization provides a secure fax number.

      Resources

      The Centers for Medicare & Medicaid Services, Key Message and Tips for Providers: Common Types of Health Care Fraud

  5. For HHH – if we were in the process of a TPE prior to the PHE…did they continue to review those claims and should we have decisions on those submissions now?

    • On January 31, 2020, Secretary Azar of the Department of Health & Human Services (HHS) declared a nationwide public health emergency. On March 13, 2020, Secretary Azar authorized waiver and modifications under §1135 of the Social Security Act retroactive to March 1, 2020. CGS understands the effect of COVID-19 on our provider community. In response to questions received regarding Medical Review Additional Document Requests (ADRs) and Targeted Probe and Educate (TPE) activity, at this time, CGS has temporarily suspended TPE reviews. Our medical review and provider outreach and education staff will continue to be available to conduct education sessions and provide answers to questions to ensure that providers understand regulatory guidelines to prevent improper payment. To reschedule a TPE educational session, request an educational session related to medical review topics, or for medical review general TPE questions please contact us at one of the email addresses peer your line of business at:

  6. For Part B, If the Recovery Auditor finds that we made an error in billing (we forgot to add a modifier) can we correct the claim to re-bill it correctly if the timely filing period has passed.?

    • Yes, when an auditor finds an error during a review, once the review is completed the provider has the right to request an appeal based on the auditors decision, since you are identifying that the error was caused by a modifier not being added this can be handled by a reopening as a clerical error. You can request a reopening or correct your modifier by using the myCGS web portal

  7. When a Home Health claim is pulled for TPE will it be pulled on a 30 day period basis or an episode basis where all periods would be included in the review?

    • Effective for claims with a "From" date on or after January 1, 2020, Change Request (CR) 11081 implements the policies of the home health Patient Driven Groupings Model (PDGM). The PDGM changes the unit of payment from 60-day episodes of care to 30-day period of care and eliminates the therapy thresholds used in determining home health payment.

  8. We have a TPE dated May 4th. Is it correct that CGS said to stop this audit and release the claims so the TPE is no longer going forward? Part B

    • On March 13, 2020, Secretary Azar authorized waiver and modifications under §1135 of the Social Security Act retroactive to March 1, 2020. CGS has temporarily suspended TPE reviews.

  9. How do you appeal TPE review findings? Do we use the redetermination form? I couldn't find one specifically for TPE

    • The redetermination request form is used for any first level of appeal regardless of the type of review/contractor decision – TPE Audit decisions can be appealed by a redetermination. All CGS forms are available at

  10. If the provider billed a level 4 and the TPE lowers it to a Level 2, we do an internal review and find it to be a level 3 – do we file the redetermination and send in a corrected claim with the 99213?

    • If you disagree with the TPE decision you can request a Redetermination with your supporting documentation

  11. How long does it take for a SMRC audit to review and respond once the requested records have been submitted?

    • The Supplemental Medical Review Contractor (SMRC) is handled by Noridian. For more details on the SMRC program you can contact Noridian Healthcare Solutions at 1-833-860-4133, or check out Noridian Healthcare Solutions SMRC Website at https://www.noridiansmrc.comExternal Website.

  12. What is the best approach if one of the claims on our payment review was billed in incorrectly. Do we do a corrected claim and still send all the documentation to you? For example, we billed with the wrong modifier. We are aware the claim was billed incorrectly and we want to correct it. Do we also acknowledge when we give the information requested that this was billed incorrectly, and we did a corrected claim?

    • Since a documentation request has already been released, you will not be able to make any changes to the records. You can acknowledge (add a letter) that while gathering the documentation it was found that the modifier was left off, and once the review is completed then you can make the corrections to your claim for consideration of any adjustments.

spacer

26 Century Blvd Ste ST610, Nashville, TN 37214-3685 © CGS Administrators, LLC. All Rights Reserved