Q1: If I am under a pre-pay audit, what are the steps in the review process?
A1: The steps are:
• The supplier submits the claim, electronically or hard copy, to the DME MAC (Medicare Administrative Contractor)
• The DME MAC sends the claim, electronically, to TriCenturion
• TriCenturion sends out the Additional Documentation Request (ADR) letter to the supplier
• The supplier sends the additional documentation to TriCenturion within 30 days
• The claim is reviewed by the medical review nurse and transmitted to the DME MAC
• The DME MAC sends the Explanation of Benefits (EOB) to the supplier
Q2: What is the time frame for the review of each claim?
A2: TriCenturion has 60 days from the receipt of additional documentation to complete the review of each claim. You should expect the process to take longer that routine claims submission
Q3: If I appeal the claims that were denied and they are overturned, will this have a positive effect on my ongoing pre-pay review?
A3: TriCenturion does monitor the appeal overturn rate and will take that into consideration with your current Charge Denial Rate (CDR) at the time of the appeal decision.
Q4: When I am on a pre-pay review, do I need to submit the documentation when I submit the claim?
A4: You should wait for the Additional Documentation Request (ADR) letter before submitting the medical documentation and return the letter with the documentation.
Q5: Will the payment of my allowed claims during an audit remain electronic?
A5: Yes
Q6: If I request additional documentation and the provider is hesitant to give me the documentation, is it acceptable for the provider to fax the documentation to TriCenturion?
A6: Yes, it is acceptable for the provider to fax the documentation to TriCenturion. However, the provider must note, on the fax cover sheet, which supplier requested the documentation.
Q7: How long will I remain on pre-pay review?
A7: Until your (CDR) is less than or equal to 20%.
Q8: Are 100% of my claims reviewed until my CDR reaches 20%?
A8: No, when the CDR drops below 75% a targeted review is initiated.
Q9: What is a targeted review?
A9: A targeted review is a review of a portion of claims submitted based on the CDR.
For example, if your CDR was 40% then only 40% of your average number of claims submitted in a month would be reviewed.
Q10: Is it not true that even though the PCA publication and CMS guidelines stated that the supplier’s level of review, is based on the CDR, the computer programs are unable to handle this, therefore 100% of the claims would be reviewed regardless of the CDR?
A10: TriCenturion has a process in place that allows a review based on the CDR.
Q11: I have a difficult time getting medical records from the physicians and from Nursing Homes. Is there a regulation that requires them to provide me with these records?
A11: Section 1842 (p)(4) of the Social Security Act states: In the case of an item or service defined in paragraph (3), (6), (8), or (9) of subsection 1861(s) ordered by a physician or a practitioner specified in subsection (b)(18)(C), but furnished by another entity, if the Secretary (or fiscal agent of the Secretary) requires the entity furnishing the item or service to provide diagnostic or other medical information in order for payment to be made to the entity, the physician or practitioner shall provide that information to the entity at the time that the item or service is ordered by the physician or practitioner.
Despite this statute, many physicians are reluctant to release medical records because of HIPAA concerns. While HIPAA requires adoption of practices to safeguard protected health information (PHI), there are exceptions for disclosure of PHI for the purposes of treatment, payment or healthcare operations. Therefore, suppliers can assure physicians that it is not a violation of HIPAA to provide a DME supplier with medical records that support the medical necessity of prescribed equipment.
Providing medical records to medical equipment suppliers falls under the disclosure of PHI for the purposes of payment. Medicare statute requires that payment only be made for items or services that are "reasonable and necessary" and payment cannot be made or confirmed without these records. Furthermore, these records may be provided without having a Business Associate Agreement with the supplier requesting the records or a release of information from the beneficiary.
LPET