Post-payment Review

90.4.7 - Post-payment Review (Rev. 4431, Issued: 11-01-19, Effective: 02-04-20, Implementation: 02-04-20) On a post-payment basis, services submitted with the QB or QU modifier, or the AQ modifier for claims with dates of service on or after January 1, 2006, will be subject to validation. Effective for claims with the dates of service on or after January 1, 2005, the date of the HPSA designation or withdrawal on the HRSA Web site or the date of designation or withdrawal in notification letters from HRSA are used as the effective date for paying the HPSA bonus. Effective for claims with dates of service on or after January 1, 2006, A/B MAC Part B A/B MACs (B) shall only include services paid with the AQ modifier for post-payment HPSA review. Services with bonuses that were automatically paid based on the ZIP code for the HPSA post-payment review process shall not be included. Additional post- payment will be conducted at the A/B MAC (B)’s discretion. Effective for claims with dates of service on or after January 1, 2009, for Medicare bonus payment purposes, A/B MACs (B) shall only consider services eligible for bonuses if the area was designated as a HPSA as of December 31 of the prior year. The post-payment review will be conducted each quarter as follows: B. Array each list of physicians by the total amount of incentive payments received. C. Select the 25 percent of physicians on each list who received the highest payments. D. Review a sample of 5 claims by each physician on each list (ensure the sample is representative of different types of settings, if applicable). E. The findings must be transmitted via CROWD (Form 1565E) to central office no later than the 75th day following the close of the CROWD reporting quarter. Physicians who appear on a list, were previously reviewed, and subsequently found to be in compliance shall be excluded from the current reporting. The 5 claim sample shall be reviewed to ensure the place of service was actually in a HPSA bonus area. In addition, effective for claims with dates of service on or after July 1, 2004, services selected as part of the 25% sample will be verified that they were provided in a mental health HPSA by any of the psychiatry provider specialties. Once a physician has incorrectly claimed incentive payments, the A/B MACs (B) shall continue to monitor the physician’s claims until they are found to be in compliance. The designations on the HRSA Web site and HRSA letters can be used to verify that services were provided in a HPSA. Physicians are permitted to submit copies of HRSA designation letters as appropriate documentation to their. If it is determined that a HPSA bonus was paid in error, the A/B MAC (B) will pursue the amount of any overpayment by directly contacting the physician and his/her billing staff. For Medicare HPSA bonus payment purposes, designations are valid for the entire calendar year regardless of whether the HPSA designation is withdrawn by the HRSA during that year.