Evaluating Effectiveness of Established Automated Edits

3.7.3.2 - Evaluating Effectiveness of Established Automated Edits (Rev. 10365; Issued: 10-02-20; Effective: 08-27-20; Implementation: 08-27-20) This section applies to MACs. MACs shall consider the following factors when looking at edit effectiveness for established automated edits: • Time and staffing needs for review and appeal reviews. MACs shall implement mechanisms (e.g., manual logs, automated tracking systems) to allow the appeals unit to communicate to the MR unit information such as when denial categories are causing the greatest impact on appeals, the outcome of the appeal, and • MACs shall maintain and make available to the appropriate CMS staff documentation demonstrating that they consider appeals in their edit evaluation process; and specificity of edits in relation to identified problem(s). The MACs should note that even an automated edit that results in no denials may be effective as long as the presence of the edit is not preventing the installation of other automated edits. The MAC shall provide the claims data necessary to the UPIC to evaluate the effectiveness of edits implemented at UPIC request. The MACs shall provide this report on a monthly basis by the 15th business day of each month. This requirement could also be met by the UPICs retrieving claim data necessary directly from the EDC if available. A. Edit Effectiveness for all Other Edits The MACs shall consider the following factors when looking at edit effectiveness for all other edits: • Time and staffing needs for review and appeal reviews. MACs shall implement mechanisms (e.g., manual logs, automated tracking systems) to allow the appeals unit to communicate to the MAC MR unit and the UPIC just specific to UPIC edits information such as which denial categories are causing the greatest impact on appeals, and the outcome of the appeal. MACs shall maintain and make available to CMS documentation demonstrating that appeal outcomes are considered in their edit evaluation process; • Specificity of edits in relation to identified problem(s); • Demonstrated change in provider behavior, i.e., the MAC can show a decrease in frequency of services per beneficiary, the decrease in the number of beneficiaries receiving the services, the service is no longer billed, or another valid measure can be used to reflect a change in provider behavior over time; • Impact of educational or deterrent effect in relation to review costs; and • The relative priorities or competing edits in terms of the number of claims/days/charges. The MACs shall test each edit before implementation to verify that the edit accomplishes the objective of efficiently selecting claims for review and to determine the edit’s impact on workload.