Beacon

Widespread 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.

Prepayment Probe Notification Article:

  • Posted in Cahaba’s ‘What’s New’ section informing providers of an upcoming Part A prepayment probe.

Additional Development Request (ADR):

  • Sent to provider requesting supporting documentation for claims included for services billed. 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 Probe Results Article:

  • Posted in Cahaba’s “What’s New” Section informing providers of probe results.

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.
  • If specific providers are identified with high error rates and the issues identified are not widespread, provider specific prepayment review will be initiated.

Education:

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