Prepayment Claims Reviews

Transcription

1 Prepayment Claims Reviews NC TIDE Spring Conference April 24, 2017 Tichina Hamer, MSL Behavioral Health Manager II DMA Office of Compliance and Program Integrity

2 Objectives Training Participants should be able to: Locate state rules and regulations regarding prepayment claims review Develop internal systems to establish a prepayment review process within the MCO setting Successfully implement prepay methods within Managed Care Organizations

3 History of Prepayment Claims Review In 2009, The Carolinas Center for Medical Excellence (CCME) was awarded the contract to conduct prepayment reviews. Review of claims include, but to not limited to: Behavioral health providers Medical providers Durable medical equipment vendors Over 190 providers have been placed on Prepayment Claims Review.

4 Methods of Processing Providers Claims Processing providers claims consist of: System processing to ensure submission of clean claims Post payment review of paid claims Review of documentation prior to payment of claims Prepayment Claims Review

5 Legislation of Prepayment Reviews North Carolina General Statute 108C-7 - Prepayment Claims Review 10A NCAC 22F Program Integrity.0104 (c) Prepayment

6 Reasons to Place Providers on Prepayment Claims Review Grounds for placing a provider on prepayment claims review includes, but not limited to: Credible allegations of fraud Aberrant billing practices as a result of investigations Data analysis Other reasons defined by the Department

7 Implementation of Payment Claims Review Internal Resources Review Tools Knowledge of applicable policies Ability to pend claims Manpower to review claims

8 Additional Implementation of Payment Claims Review Methods to notify provider of selection of prepayment claims review Awareness of timely claims payment processes Awareness of volume of claims previous paid Tracking provider progress

9 Developing Prepayment Claims Review Process Provider s claims volume Review provider s history of billing volume Abilities of Claims system Internal Resources Identify Reviewers Knowledge of Applicable Policies Tools to document review of claims

10 Notification of Provider NCGS 108C-7 (b)(1-6) lists the contents the provider s notice must include prior to placing a provider on prepayment claims review. No less than 20 calendar days prior to instituting prepayment claims review, the provider must be notified of: The decision to place the provider on prepayment claims review. The process for submitting claims for prepayment review.

11 Participation in Prepayment Claims Review Per NCGS 108C-7(b), Providers shall not be entitled to payment prior to claims review by the Department. Per NCGS 108C-7(f), A provider may not appeal or otherwise contest a decision of the Department to place a provider on prepayment review.

12 Submission of Claims Claims may be submitted through an electronic payment system or paper process. In order to process clean claims, providers are required to submit documentation to support claims billed.

13 Review of Claims Claims submitted for prepayment review must be processed within 20 calendar days from the date of submission. When documentation is missing, the provider must be notified in writing. Notification must be provided to the provider within 15 calendar days from receipt of the claims Reviewers have an additional 20 calendar days from receipt of the documentation to process the claims. Must follow the timely filing rules to process claims

14 Review of Documentation Utilize a Division of Medical Assistance approved tool to review documentation (Example)

15 Passing Prepayment Claims Review In order to pass Prepayment Claims Review, providers must meet the following: At least 70% clean claims rate Timeframe of 3 consecutive months Remove provider once the passing standard has been met.

16 Addressing Prepayment Claims Issues with Providers Ensure policies have clear guidelines on how to manage non-compliance with the prepayment claims review program. Potential issues: Failure to submit documentation requested Notification returns as undeliverable or not accepted Holding claims Failure to pass prepay

17 Failure of Prepayment Claims Review Providers cannot continue on prepay status longer than 12 months. If the provider has not met the passing standard within 6 months, sanctions may be implemented. OR Sanctions also include: Continuation of pre-pay Termination of the Medicaid Administrative Participation Agreement Launching an investigation

18 Example of Implementation of Prepayment Claims Review at Managed Care Organization

19 Benefits of Prepayment Review Benefits to Providers: Educational Component Allows providers to develop better practice standards Reduction of duplicative monitoring of claims for the same issue Assists providers with identifying and developing internal controls

20 Benefits of Prepayment Review Benefits to Managed Care Organization: Ability to provide technical assistance for errors identified Ensure compliance with clinical policies prior to payment Ensure Medicaid dollars are paid appropriately Reduced cost of pay and chase

21 Tichina Hamer, MSL Behavioral Health Manager II Division of Medical Assistance, Office of Compliance and Program Integrity (919) Questions