Claims Review

8.3.2.3.1 – Claims Review (Rev. 10228; Issued: 07-27-20; Effective: 08-27-20; Implementation: 08-27-20) While a payment suspension does not stop claims processing, CMS prefers that all claims being processed during the payment suspension period be reviewed on a prepayment basis for reasonableness and necessity. If fraud-related, the review of claims should also address whether services were actually rendered as billed. This will ensure that the withheld payments only include payable claims to be used in the disposition of the funds when the final overpayment(s) are determined. A. Claims Review Once a payment suspension has been imposed, the MACs and UPICs shall follow the claims processing and review procedures in accordance with Pub. 100-08, chapter 3. MACs and UPICs shall ensure that the provider is not substituting a new category of improper billings to counteract the effect of the payment suspension. (If such a situation arises, the UPIC shall modify the payment suspension accordingly with CPI’s approval.) If the claim is determined to not be payable, it shall be denied and the provider afforded its appeal rights. For claims that are not denied, the MAC shall send a remittance advice to the provider showing that payment was approved but the actual funds not sent. UPICs are not required to perform 100 percent prepayment review of claims processed during the payment suspension period. If prepayment review is not conducted, a post- payment review shall be performed on the universe of claims adjudicated for payment during the payment suspension, prior to the issuance of the overpayment determination. In order to reduce the burden of resources, if only specific claim types (or certain codes) are the subject of noncompliance, the UPIC may elect to only place such claims types on prepayment or post-payment review. UPICs shall consult with CPI for guidance when resources may be better utilized employing statistical sampling for overpayment determination(s). UPICs shall use the principles of statistical sampling for overpayment estimation found in section 8.4 of this chapter to determine what percentage of claims in a given universe of withheld claims payments are payable. In all cases involving a post- payment review, the UPIC shall follow the rules of reopening as defined in 42 C.F.R. §405.980 and inform the provider that the claims are reopened in accordance with the regulations when requesting records and supportive information. B. Review of Suspected Fraudulent or Overpaid Claims: The UPIC shall follow procedures in Pub. 100-08, chapter 3, section 3.6 in establishing an overpayment. The overpayment consists of all claims in a specific time period(s) determined to have been paid incorrectly. The UPIC shall make all reasonable efforts to expedite the determination of the overpayment amount. The UPIC shall account for binding revised determinations or binding reconsiderations in its overpayment determination in accordance with 42 CFR §405.984. NOTE: Claims selected for post-payment review may be reopened within one year for any reason or within four years for good cause. (See 42 CFR §405.980.) Cost report determinations may be reopened within three years after the Notice of Program Reimbursement has been issued. Good cause is defined as new and material evidence, error on the face of the record, or clerical error. The regulations have open-ended potential for fraud or similar fault. The exception to the one-year rule is for adjustments to DRG claims. A provider has 60 calendar days to request a change in an assignment of a DRG. (See 42 C.F.R. §412.60(d).)