Provider Specific Probe Review:
When an individual provider is identified as being statistically different from his or her peers, a probe review is conducted. A small sample of claims (20-40) suspends randomly to MR and an ADR (Additional Documentation Request) is sent to the
provider requesting documentation to support the services billed. The provider has 45 days to return the documentation.
Review is performed when the documentation is received to determine 1) if the service has been provided, 2) has been coded correctly, 3) is reasonable and necessary, and 4) is a covered Medicare benefit. If no records are received, the claim is denied
for "no response".
The provider is notified of the results by individual education letter. This may result in no action necessary, collection of dollars paid in error (Postpay), additional education and/or referral for prepay audit. In all cases, follow up will occur to
ensure the problem(s) has been corrected and maintained.
If continued non- compliance is demonstrated despite educational interventions, a referral may be made to the appropriate Program Safeguard Contractor for investigation and possible suspension, per the PCA process.
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Widespread Probe Review:
This is a medical review performed when a widespread problem is identified by data analysis and is intended to validate whether a problem exists or not. An example would be a dramatic increase in the billing of a specific type of bill or CPT code.
A random sampling of 100 claims billed for the identified issue suspend to Medical Review and an ADR is sent to the provider requesting additional documentation to support the service(s) billed. The provider has 45 days to return the documentation.
Review is performed when the documentation is received to determine 1) if the service has been provided, 2) has been coded correctly, 3) is reasonable and necessary, and 4) is a covered Medicare benefit. If no records are received, the claim is denied
for "no response".
The providers are notified of the results by Newsletter article, website posting and/or individual education letters. This may result in no action necessary, collection of dollars paid in error (Postpay), additional education and/or referral for prepay
audit. In the performance of the widespread probe review, a specific provider may stand out. The nature and scope of the problem identified with this provider will direct the PCA process to a provider specific probe or a prepay edit/audit. In all cases,
follow up will occur to ensure the problem(s) has been corrected and maintained.
If continued non- compliance is demonstrated despite educational interventions, a referral may be made to the appropriate Program Safeguard Contractor for investigation and possible suspension, per the PCA process.
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