Medicare Compliance & Reimbursement
Feds Moving Toward Reduced Medical Review Period
Carriers can still drive physicians nuts with documentation requests and prepayment reviews--but soon, at least, there may be a time limit.
The Centers for Medicare and Medicaid Services published a proposal to limit the time a carrier can put on a physician's prepayment medical review to one year. And if the physician's error rate decreases by 70 percent, then the carrier has to let the physician off medical review sooner, according to the proposal in the Oct. 7 Federal Register.
Here's the catch: If a doctor's error rate is still too high at the end of a year of medical review, the carrier can send the doctor on to the Program Safeguard Contractor, and also continue to educate the doctor and perform postpayment reviews. If a physician stops billing one inappropriate code only to start billing another, the carrier may be able to extend the prepayment review past a year.
After a year of prepayment medical review, being sent on to the PSC could be an even worse fate, worries Catherine Brink, president of Healthcare Resource Management in Spring Lake, NJ.
Even under the new time limit, physicians on medical review for a whole year are doing something very wrong, says Ben Frosch with Frosch Medical Consultants in Plantation, FL. Here are some things physicians can do to escape as quickly as possible:
• Develop a working relationship with the auditor, urges Frosch, a former carrier hearing officer. Part of the carrier's mission is to educate physicians. "Do not make your encounters with your prepayment auditor adversarial," Frosch warns. "It is not going to help you."
• Contact carrier rep: If a doctor is billing a lot of a single big-ticket code, the carrier may put him on prepayment review for that particular code, warns Brink. But if the doctor is billing legitimately, keep the lines of communication open with the carrier.
• Get outside help: A physician may want to hire a consultant to help him figure out if he's really doing something wrong, Frosch advises.
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