Beacon

Provider Specific Prepayment Probe Review Process

Analysis:

  • Through analysis of CMS identified vulnerabilities, data analysis, medical review of claims and other reports, potential service specific and/or provider specific inappropriate billing is identified.

Provider Specific Prepay Notification Letter:

  • Sent to provider to inform them they have been selected for prepayment claims review along with a comparative billing report showing the provider a comparison of their billing to other providers billing and informing them they are above average for their specialty.

Additional Development Request (ADR):

  • Sent to provider requesting supporting documentation for claims included in the probe review. The ADR letters will be mailed and /or the claim in question will be in status location S B6001 that identifies claims in FISS that are in an ADR status/location.

Prepayment Claim Review:

  • Provider Specific

Prepayment Results Letter:

  • Sent to provider with results of prepayment claims review.

Corrective Action:

  • If dollar error rates are high and billing patterns are not in compliance with CMS directives, the probe will be continued as a widespread targeted prepayment review.
  • If dollar error rates are low and billing patterns are within compliance with CMS directives, a results article will be posted with educational material included on Cahaba’s “What’s New” section and the prepayment probe will be closed.

Education:

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