Part B Legacy Medical Review
Wisconsin Physicians Service (WPS) Medicare continues to be committed to supporting the reduction of the national paid claims error rate. At the same time, WPS Medicare will do its part to protect the national trust account for the citizens of this wonderful nation. In an effort to support these goals, the WPS Medicare Medical Review (MR) Strategy for the Fiscal Year (FY) 2007 will focus on initiatives that are intended to correct aberrant billing practices by the provider community. This approach will be consistent with recent mandates from the Centers for Medicare & Medicaid Services (CMS).
A WPS multi-disciplinary team comprised of management representatives from Medical Review, Claims, Policy, Medicare Central Data Unit (MCDU), Provider Outreach and Education (POE), and Quality Improvement (QI) was instrumental in the development of the new fiscal year MR Strategy. During the strategy development stages, the team utilized various sources as the impetus for the strategy. This team explores high level issues driven by data analysis, which may come from Comprehensive Error Rate Testing (CERT), the Office of the Inspector General (OIG), CMS, referrals, and other sources.
The activity of the strategy planning and development team is usually work in progress, requiring recurrent discussion, as well as ongoing review, of newly developing data. The planning team also uses a prioritization tool to rank Medical Review problem focus areas according to priority. Semi-annual BESS data, local claims data and program vulnerability issues are utilized to determine the potential for, and the extent of, a problem within our jurisdiction. After problems have been identified by the prioritization process, they are reviewed and ranked by the MR Strategy Oversight Committee. This group meets quarterly to assess any new data findings and/or exchange information for reaffirmation of each problem's prioritization status.
Providers for whom data analysis indicates a potentially significant billing issue may receive communication from Medical Review identifying the potential billing problem, as well as providing a Comparative Billing Report (CBR). The CBR will compare individual provider data to jurisdictional group data. The letter will present an opportunity for the provider to review the information and conduct a self-audit to identify any coverage or coding errors that may have occurred. If errors are identified, the provider may submit a corrected claim with the appropriate billing and/or, if necessary, submit a voluntary refund to WPS Medicare.
When subsequent data analysis and/or provider communication tracking reveals there has been no significant change in the individual provider's billing patterns, a provider-specific probe review may be performed. In the event that it is deemed necessary to conduct a probe review, Medical Review will implement the following actions at its completion:
- Include in the probe findings notification letter the name and contact information for a POE staff person who may be contacted for the purpose of follow-up education
- Conduct a one-on-one conference call with the provider, MR and a POE representative to review and discuss the issues related to the review
- Provide additional post-probe education through POE, if requested by the provider.
There are multiple Medical Review issues for a wide range of services that will be visited in FY 2007. Issues of incomplete documentation by teaching physicians proved to be a major concern in the FY 2006 probe reviews of subsequent hospital visits, and will continue to be a topic of attention during the new fiscal year. As always, the provider's documentation of any services will play a large part in determination of both the medical necessity and the allowable level of billed services.
Besides Subsequent Hospital Visits, additional issues that will be visited by Medical Review in FY 2007 are:
- Established Office Visits
- Chiropractic Manipulations
- Group Psychotherapy
- Diagnostic Testing (Nerve Conduction Studies)
- Office Consultations
- Inpatient Consultation
Medical Review will continue to provide support in the form of clinical expertise to Provider Outreach and Education (POE) for their educational initiatives. We maintain that most providers want to bill Medicare appropriately, and given the educational support, will change aberrant billing behaviors. As part of our educational initiatives, WPS Medicare will often reference or utilize policy in the form of Local Coverage Decisions (LCD), National Coverage Provisions (NCP), and National Coverage Decisions (NCD).
Our WPS Medicare team is committed to the success of the jurisdictional FY 2007 Medical Review Strategy. Members of this team include the Carrier Medical Directors, Policy Development Staff, Outreach Educational Professionals, Medical Review Nurse Analysts and management staff, Data Analysts and Statisticians, Publication Specialists and Customer Service Representatives.
