The Medicare Program Integrity Manual, Pub 100-08 Transmittal 527 reflects a change request due to providers requesting to know what areas CMS contractors are currently reviewing. Medicare Administrative Contractors (MACs) and supplemental Medical Review Contractors (SMRCs) will be required, starting September 5, 2014, to maintain a public website that displays what types of issues are being reviewed.  CERT contractors select claims randomly and therefore are not required to notify providers of their review intentions.  However, when a MAC data analysis reflects provider-specific errors that need confirmation by requesting and reviewing documentation to support the claim, the MAC will review a small sample of claims (“probe” usually of 20-40 claims) of potential problem claims either prepayment or post-payment—CMS encourages prepayment to confirm whether or not the claims were billed in error in order to help prevent improper payments.  Therefore, this will ensure that the MAC is reviewing activities at specific problem areas. The MACs shall notify providers they select, prior to the beginning of their review, by sending an individual written notice and should indicate if their review is on a prepayment or post-payment basis.  At a minimum, MACs will select providers based on the following:

  • The MAC has identified questionable billing practices (examples: non-covered, incorrectly coded or incorrectly billed services) through data analysis
  • The MAC receives alerts from other MACs, Quality Improvement Organizations (QIOs), CERT, Recovery Auditors, OIG/GAO, or internal/external components that warrant review
  • The MAC received complaints

Reference: PIM Pub 100-08 Transmittal 527 Avoiding Denials—How do I do this? Palmetto GBA recently conducted a review in North Carolina, South Carolina, Virginia and West Virginia April 1-June 31st.  They provided great tips on how to avoid a denial.  I have a few listed below for you.

  1. Documentation should support treatment of a condition for which the patient was receiving inpatient hospital services or for a condition that arose while receiving care in a SNF for treatment of a condition for which the beneficiary was previously treated in the hospital
  2. Submit all documentation to support the services billed and the medical necessity of those services.Services must be medically reasonable and necessary and supported by documentation
  3. Submit a copy of the qualifying hospital stay transfer/discharge summary that relates to the services provided in the SNF
  4. Submit the physician certification and recertification of the need for continuing daily skilled SNF services
  5. Submit the MDS for each RUG code billed, even if more than one RUG is billed;you may need to include all MDS’ from the start of care through the dates of service billed

Submit all documentation used to support the MDS—this includes documentation to cover the look back periods for each MDS Reference, more tips, and Palmetto GBA’s comprehensive findings report, click here.