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Medicare prepayment review comes to eye care

June 5, 2012

The rapid expansion of a U.S. Centers for Medicare & Medicaid Services (CMS) initiative, launched last year to crack down on improper billing and claim errors, has meant more optometrists across the nation are receiving Medicare prepayment review notices, according to the AOA Third Party Center Executive Committee.

The new prepayment review program means health care practitioners, including optometrists, will have to more diligently avoid common claim filing errors – such as coding mistakes or missing signatures – if they wish to ensure prompt payment, according to AOA Third Party Center Executive Committee members.

The AOA Advocacy Group is monitoring the new program closely to make sure claims from optometrists are not being improperly rejected.

“Medicare audits are increasing in frequency. Optometry is NOT immune to these audits. Remember that proper documentation is always required on claims. Never ignore an audit request,” said committee member Rebecca Wartman, O.D.

Traditionally, Medicare carriers have conducted post-payment reviews. Health care practitioners were asked to provide any missing documentation and return payments if they could not.

However, recent federal legislation has now authorized Medicare auditors to review randomly selected claims prior to payment.

The auditors then ask practitioners to provide any missing information before issuing a check or funds transfer. The prepayment audit program was launched in 2010.

In February the CMS more than doubled the size of the new audit program to cover 2.7 million claims a year, up from 1.2 million claims.

Shortly thereafter, the AOA Advocacy Group began receiving questions from optometrists around the nation regarding additional documentation requests (ADRs) they had received from Medicare carriers prior to payment.

Wisconsin Physician Services (WPS), the Medicare carrier for a number of Midwestern states, conducted two optometry-specific probe reviews, on CPT codes 99213 and 99214, in 2011.

In April, the medical review department for Palmetto GBA, the Medicare administrative carrier (MAC) for North Carolina, South Carolina, Virginia, and West Virginia, announced it will perform a service-specific pre-pay “probe” review of outpatient ophthalmic claims, focusing on 13 common ophthalmic codes found to be used with high frequency.

The carrier plans to review about 100 claims in each of the four states for each of the 13 services.

“Probe” reviews are conducted to determine if there is evidence of a widespread billing problem. The 5,200-claim review is considered unusually large for a Medicare contractor,and a number of eye care practitioners in those states may receive notices, the AOA Advocacy Group notes.

“A Medicare carrier medical review probe may be coming to your area soon,” said Dr. Wartman.

Practitioners should watch carefully for prepayment review notices in the mail and be prepared to promptly provide any information required by auditors, Dr. Wartman said.

Practitioners have only a limited period of time to respond.

“Remember these are prepayment reviews so the claim will not be processed until the provider responds to the request to send their records into the carrier,” Dr. Wartman said.

“Fortunately, optometrists can generally take some relatively simple steps to avoid common claim-filing errors and thereby avoid prepayment ADRs,” she added.

“Adequate documentation is the primary concern for auditors,” Dr. Wartman said.

Optometrists are asked to report all prepayment review notices to their state optometric association’s Medicare Carrier Advisory Committee (CAC) representative and third-party committee as well as the AOA Third Party Center Executive Committee.

“Reviews may target Medicare prepayment audits of ophthalmology procedure codes,” an AOA Third Party Committee advisory on the prepayment review program appears in the June issue of AOA News.

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