This consists of Medical Review performed prior to payment and may or may not require submission of records. This may involve a system edit to prevent payment for non-covered and/or improperly coded services. There are several types of prepay review:

In this type of review, decisions are made at the system level without the intervention of contractor personnel. Examples of this would be issues concerning the relationship between diagnoses, provider specialty, LCD and/or place of service.

This type review requires the intervention of MR staff because it cannot be automated. It may involve submission of attachments other than medical records such as EKG strips or invoices and requires the reviewer to access the Claims History File and/or Internal Guidelines.

This type of review requires development for medical records and the evaluation of the documentation submitted. This requires a clinician who has a working knowledge of coverage and LCD’s.

There are two types of prepay audits – services specific and provider specific. As we develop this web site and particularly the MR webpage, the intent is to provide direct links for the provider to access each audit for information about the purpose and required documentation.

This type of audit is put into place based on data analysis that identifies a problem. Typically, this audit will suspend claims based on the comparison of two or more element values on the same claim or they may compare dates with the medical record to determine medical necessity. In either case, documentation is requested and the claim may be denied or paid, depending on whether the documentation supports the service billed.

This is the result of problem identification and may suspend all of the claims for a provider who has demonstrated unusual practice patterns. Documentation is requested and the claim may be denied or paid, depending on whether the documentation supports the service billed.

Regardless of the type of audit, each audit implemented is evaluated at least quarterly for effectiveness. Audits are taken down when the denial rate falls to 20% or less. That said, this does not mean that every audit automatically runs at least a quarter. Provider response to correct problems expedites removal from audit and all results and recommendations are shared with CMS.