Part B Insider (Multispecialty) Coding Alert

Published on Thu Sep 15, 2005 PDF

3 tips for getting off medical review as fast as possible

Your carrier can still drive you nuts with documentation requests and prepayment reviews--but soon, at least, there may be a time limit.

The Centers for Medicare & Medicaid Services published a proposal to limit the time your carrier can put you on prepayment medical review to one year. And if your error rate decreases by 70 percent, then the carrier has to let you off medical review sooner, according to the proposal in the Oct. 7 Federal Register (Vol. 70, No. 194, pp. 58649-58654).

Here’s the catch: If your error rate is still too high at the end of a year of medical review, the carrier can send you on to the Program Safeguard Contractor (PSC) and also continue to educate you and perform postpayment reviews. If you stop 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, if you’re on medical review for a whole year, then you’re doing something very wrong, says Ben Frosch with Frosch Medical Consultants in Plantation, FL. Here are some things you can do to escape as quickly as possible:

1. Develop a working relationship with your auditor, urges Frosch, a former carrier hearing officer. Part of the carrier’s mission is to educate you. “Do not make your encounters with your prepayment auditor adversarial,” Frosch warns. “It is not going to help you.”

2. Contact your carrier rep: If you’re billing a lot of one big-ticket code, your carrier may put you on prepayment review for that particular code, warns Brink. But if you’re billing legitimately, keep the lines of communication open with your carrier.

3. Get outside help: Hire a consultant to help you figure out if you’re really doing something wrong, Frosch advises. And if you are, then the consultant can help you get back on track--and off your carriers’ audit list.