Part B Insider (Multispecialty) Coding Alert

Published on Fri May 23, 2003 PDF

Why is the insurance carrier picking on you? It may seem random, but there's usually a reason.

If your carrier appears to have singled you out for intensive review of all of your claims, either before or after payment, then chances are you were billing for something in a way that attracted the carrier's attention. Figuring out what triggered the radar can be the first step to extricating yourself.

Focused medical review can take a few different forms, billing experts say. It can involve prepayment or postpayment review of claims. It can also involve a random sampling of your claims, or claims focused on a few hot-button codes. And the proportion of your claims run through the wringer can vary as well.

What doesn't vary is that focused medical review is a nuisance and a drain on resources, says Catherine Brink, president of HealthCare Resource Management Inc. in Spring Lake, N.J. A prepayment review may slow your cash flow to a trickle, while a postpayment review will force you to chase documentation and compile massive dossiers for the carrier.

A review may be random, but the fact that you're targeted probably isn't, says consultant Dwayne Thomas with Healthcare Management Solutions Inc. in Monsey, N.Y. The first thing you must figure out is, "What did Medicare find in their audit of your files that caused them to want to take a second look at your claims?" Thomas notes.

Usually, he says, carriers will give you "a couple of chances" before putting you on FMR. These may take the form of regular audits of your certificates of medical necessity or requests for additional documentation on a few claims. If these audits turn up a sample that doesn't meet their standards, they may proceed to the next step.

Figuring out what the carriers saw in your claims that made them decide to put you on review means looking back at earlier audits and examining the claims you sent in previously, Thomas says.

You may not realize you're on review at first when the carrier requests details on 10 claims, then another 10 claims, until it becomes obvious you're being targeted, Brink says. You should look into ways you can clean up your act before you do anything else, she adds.

"After you see a pattern developing and it's becoming frequent, you obviously don't want to just sit back" and do nothing, Brink says. She advocates becoming proactive and contacting someone at the carrier. "You want to try to nip it in the bud and get on the phone to the carrier and find out what you can do to alleviate this problem." Hopefully, your billing staff has established a good working rapport with at least one carrier rep, and that person may be able to guide you to the right office.

There's no set protocol for getting off review, Thomas says. Usually, the carriers decide when to take you off review based on statistical analysis. So if your claims reach a certain percentage threshold of accuracy, you'll be home-free. "If you can put through 100 percent clean [claims], there would be no reason for Medicare to utilize the manpower," Thomas says. "The objective of a focused medical review is to educate the suppliers as much as possible."