MR Activities and Improper Payment Interventions Planning

7.3.2.4 - MR Activities and Improper Payment Interventions Planning (Rev. 599, Issued: 06-26-15, Effective: 12-07-15, Implementation: 12-07-15) The MAC shall provide updates on MR activities and other improper payment interventions planned and/or continued in order to improve the problem and meet improvement goals. The MAC shall provide updates on the information described in the IPRS. Such information includes, but is not limited to: • Baseline problem measurement reported in IPRS compared to problem measurement after intervention implementation (may be provider-specific and/or service-specific). The baseline problem measurement from the IPRS and current problem measurement in the SAR shall be the same type of error measurement that was stated in the IPRS. • Differences in the number of providers and/or services undergoing MR activities and other intervention as reported in the IPRS as what has been observed at the time the SAR is finalized. • Improvement goal revisions, as appropriate. Effectiveness of the MR activities and improper payment interventions in meeting the goal shall be addressed. These updates shall be stated in measureable terms that are data driven. • Any identified obstacles regarding the MR activities or improper payment interventions to achieve the improvement goal and suggestions for improvement. • For each prioritized problem, the contractor shall report on probe reviews conducted, as appropriate. Detailed information shall include: o Number of probe reviews identified: The number of probe reviews the MAC planned for a specific problem and the type of data and/or analysis used to determine the number of probes. o Number of probe reviews initiated: A subset of the number identified. This number conveys the actual number of probe reviews effectuated to date. Generally, the probe initiation date is the date a request for medical records is sent to the provider(s). The date of the probe start shall be included. o Type of probe review (i.e., pre-pay vs. post-pay, provider-specific vs. service specific) o Number of probe reviews completed: This number conveys the number of probe reviews concluded. It is the number of probe review cases for which corrective action has been initiated. o Probe Results: current problem measurement determined by the probe, progress towards goal, effectiveness of probe edit. • For each prioritized problem , the contractor shall report on targeted reviews conducted, as appropriate: Detailed information shall include: o Number of targeted reviews identified: The number of targeted reviews as well as the subject of targeted reviews (benefit, provider type, and provider specific) that the MAC planned for a specific problem, and the type of data and/or analysis used to determine the number. In the case of more than one service within a benefit or provider type, the benefit or provider type should be grouped under a general heading in the problem description. However, when reporting the number of identified target reviews planned, the SAR should clearly report the number planned for each code, or range of codes representing the specific service or provider type (Diagnosis Related Group (DRG), Healthcare Common Procedure Coding System (HCPCS), ICD-10) within the benefit or service description. An example is, “Physical Medicine & Rehabilitation: the total number identified for targeted reviews is x number. For physical medicine & rehabilitation CPT code XXX-traction, mechanical, x number of targeted reviews are planned. For physical medicine & rehabilitation code range XXX1-XXX3, therapeutic procedures, x number of targeted reviews are identified (for a total of x number of identified target reviews).” Start date of the targeted review and baseline problem measurement shall be included. Similarly, if targeted reviews are planned for specific providers, the total number of providers, the states in which they practice and the service, procedure or diagnosis codes subject to the specific provider targeted claims shall be included in the SAR. An example is, “ESRD, dialysis centers: x number of centers have been identified for targeted reviews. The focus for each dialysis center on targeted review will be XXX CPT Code, extra hemodialysis session. For each center identified, x number of targeted reviews are planned.” The start date and the baseline problem measurement shall be included. o Number of targeted reviews initiated: This number is a subset of the number described above, “Number Identified”. It is the actual number of providers or services activated for targeted review. As described earlier, the SAR shall clearly identify the focus of the targeted review: the procedure, diagnosis or DRG code, or place of service, etc. The percentage of claims to be stopped by an edit for each targeted review shall be included. o Type of targeted review (i.e., random v. 100 percent, pre-pay v. post-pay, provider-specific v. service-specific) o Number completed: This number conveys the number of targeted reviews concluded. It is the number of targeted review cases for which corrective action has been initiated. o Targeted Review Results: current problem measurement, progress towards goal, effectiveness of edit. • Other MR activities and improper payment interventions taken to address the specific prioritized problem and the effectiveness of the interventions. If analysis of the MR activities and other improper payment interventions shows that the improvement goals have been achieved for a specific prioritized problem, the MAC shall determine if the improved provider billing behavior or decrease in IPR is sustainable. If so, the MAC shall consider closing that problem and/or reprioritizing their problem list. The MAC shall include a description of the analysis used to make the determination that the improvement goal was met and rationale to support the closing and/or reprioritizing of the problem. Conversely, if the results of the SAR convey ineffectiveness of the MR activities and improper payment interventions, the SAR shall include modified plans for the areas of ineffectiveness of the IPRS. The result of this analysis shall lead the MAC to design future MR activities and improper payment interventions aimed at achieving the revised or same improvement goals.