Vignettes

3.7.1.2 - Vignettes (Rev. 377, Issued: 05-27-11, Effective: 06-28-11, Implementation: 06-28-11) This section applies to MACs. The following vignettes provide guidance on how the MACs shall characterize and respond to varying levels of confirmed errors. These are examples of results from medical review accompanied by suggested corrective actions. This information should only be used as a guide and is not meant to be a comprehensive list of vignettes nor an inclusive list of administrative actions. The MAC MR department shall include communication and follow-up with provider outreach and education (POE) throughout the PCA process to coordinate efforts toward problem resolution. The MACs shall monitor trends indicating widespread educational need and shall ensure that POE staff has access to copies of all MR provider notification and feedback letters so they are prepared for provider requests for education (See IOM Pub. 100-04, chapter 20, §3.4.2, for further information). 1. Twenty claims from one provider are reviewed. Once claim is denied because a physician signature is lacking on the plan of care. The denial reflects 7 percent of the dollar amount of claims reviewed. Judicious assessment of medical review resources indicates no further review is necessary at this time. The MAC uses data analysis to determine where to target medical review activities in the future. 2. Forty claims from one provider are reviewed. Twenty claims are for services determined to be not reasonable and necessary. These denials reflect 50 percent of the dollar amount of claims reviewed. One hundred percent prepayment review is initiated due to the high number of claims denied and the high dollar amount denied. The MAC provides notification to the provider about specific errors made and makes a priority referral to POE to inform them of the severity of the problem. 3. Forty claims from one provider are reviewed. Thirty-five claims are denied. These denials reflect 70 percent of the dollar amount of claims reviewed. Payment suspension is initiated due to the high denial percentage and the Medicare dollars at risk. The MAC provides notification to the provider about the specific errors made and makes a priority referral to POE to inform them of the severity of the problem. 4. Forty claims from one provider are reviewed. Thirty-three claims are denied. These denials reflect 25 percent of the dollar amount of the claims reviewed. The MAC provides notification to the provider about the specific errors made. The MAC initiates a moderate amount (e.g., 30 percent) of prepayment medical review to ensure proper billing. 5. Thirty-five claims from one provider are reviewed. Thirty claims are denied representing 75 percent of the dollar amount of the claims reviewed. Many of the denials represent services provided to beneficiaries who did not meet the Medicare eligibility requirements. The MAC provides notification to the provider about specific errors made and makes a priority referral to POE to inform them of the severity of the problem. A consent settlement offer is made but declined by the provider. A postpayment review of statistical sampling for overpayment estimation is performed and an overpayment is projected to the universe of similar claims from the provider. Overpayment collection is initiated. 6. Twenty-five claims from one supplier are reviewed. Five claims representing 5 percent of the dollar amount of the claims are denied. This supplier is known to the DME MAC as one who has a significant decrease in billing volume when targeted medical review is initiated. The DME MAC is concerned that this supplier may be selectively submitting bills when placed on medical review and chooses to continue some level of prepayment medical review despite the low error rate. 7. Twenty claims from one provider are reviewed. Ten claims are denied for incomplete physician orders representing 65 percent of the dollar amount of the claims. The MAC issues a letter to inform the home health agency (HHA) about the denials and the reason for the denials. In response to the notification letter, the agency owner initiated a mandatory training program for select staff. The HHA was put on 30 percent prepayment medical review. Results of the review indicated an improvement in the error rate to 30 percent (based on dollars denied divided by dollars reviewed). On appeal, most of the denials were overturned. The MAC consults with the ALJ to understand why the cases are being overturned and consults with the RO on appropriate next steps.