(February 29, 2012): In the past few weeks, AdvanceMed Corporation, the Zone Program Integrity Contractor (ZPIC) for Regions II and V (covering the Northwestern and Southeastern portions of the United States, respectively), appears to have significantly expanded the number of Georgia prepayment reviews it is conducting. More specifically, AdvanceMed appears to be focusing on hospices, psychiatric services and pain management, practice areas where problems has been identified by the government in the past. From calls we have received, it does not appear that only metropolitan area providers are under scrutiny. Rather, Georgia prepayment reviews appear to be occurring throughout the entirety of the State. To be clear, the government’s increasing use of prepayment review is not surprising — it is consistent with their overall efforts to prevent improper coding and billing practices from occurring in the first place. The Centers for Medicare & Medicaid Services (CMS) are understandably frustrated with old, tired enforcement tactics which relied on “Pay and Chase” strategies.
I. As Georgia Prepayment Reviews Move Forward, What Steps Can You Take to Avoid this Initiative?
In most cases, health care providers are targeted and placed on prepayment review because of: (1) data mining has identified the provider as an “outlier,” or (2) a complaint has been filed against the provider. The best preventative measure you can take is to design and implement an effective Compliance Plan. As a first step, you should conduct a “GAP Analysis” to determine whether your operations, coding and billing practices fully meet applicable laws, regulations and guidelines. If not, remedial action must be taken to put the organization back on the right path. During this process, you will likely learn how your coding and billing practices compare to those of your peers. Should you find that your practices result in the organization appearing to be an “outlier,” it is essential that you determine how and why your practices differ from those of similarly situated providers. You may or may not be doing wrong. If you are handling claims incorrectly, fix them and return any monies owed to the contractor. If you believe that your practices are compliant, that’s fine — but you better be prepared to respond to an audit.
II. Don’t Wait to be Audited – Review Your Practices Now!
Notably, when AdvanceMed places a health care provider on prepayment review, the claims being scrutinized are likely associated with services performed in the last week or two. This means that providers currently have the opportunity to assess and potentially correct their documentation practices if deficiencies are identified. We recommend that all Georgia providers examine their medical records and critically determine whether they actually meet the relevant criteria for reimbursement. Pull applicable Local Coverage Determination (LCD) rules and carefully review the medical necessity, coverage and documentation requirements set out in the contractor’s guidance. Are your documentation, coding and billing practices compliant?
III. How Should a Georgia Provider Respond if They Have Already Been Placed on Prepayment Review?
The prepayment review process can be long, complex and challenging. Moreover, the lack of a quick payment turnaround can be devastating on a small practice’s cash flow, and similarly inhibit larger entities from effectively navigating the revenue cycle. This problem is only exacerbated by the fact that AdvanceMed, as a ZPIC, is not obligated to return a decision on prepayment review claims to a provider within a specified time frame. Unlike Medicare Administrative Contractors (MACs), who, according to the Medicare Program Integrity Manual (PIM) Chapter 3, Section 220.127.116.11 F, must make and issue a decision within 60 days of receiving a medical record for prepayment review, ZPICs are not under the same duty to quickly make decisions on claims. The PIM is entirely silent on what the time frame is for ZPICs to conduct prepayment review and issue notification to the concerned provider. This may result in ZPICs, such as AdvanceMed, taking an inordinate amount of time to complete their prepayment review of your claims.
During this ongoing effort by AdvanceMed, Georgia providers should expect that prepayment review will take 90 – 180 days on average from when AdvanceMed receives the relevant medical records. Moreover, based on average denial rates we have seen in the past, providers should expect that 60 – 75 percent of their claims may be denied by AdvanceMed (although it is not uncommon for us to see denial rates at or approaching 100 percent). Upon denial of these claims, providers then have the right to take these claims through the Medicare administrative appeals process. As some of you may know, this is also a long process which usually culminates in a hearing before an Administrative Law Judge (ALJ). Regardless of your experience in this area, it is important to remember that qualified counsel can greatly assist you in developing and presenting arguments and evidence to the ALJ, as well as ensuring that all supporting documentation is included in the medical record. As AdvanceMed continues its prepayment review initiative in Georgia (and possibly expands this effort into surrounding states), providers should take a second look at their documentation and make sure it passes muster. The time to do this is now, not when AdvanceMed is knocking at your door.
Liles Parker is a full service law firm with attorneys experienced in representing providers in Medicare postpayment audits and counseling providers on prepayment review strategy. Moreover, our firm is skilled at conducting mock audits, compliance reviews and internal audits and investigations to ensure compliance with applicable laws and regulations. For a free consultation about your case, please feel free to call us at 1 (800) 475-1906.