First convened in September 2007, the Chiropractic Summit represents leadership from some 40 organizations within the profession. The Summit meets regularly to collaborate, seek solutions, and support collective action to address challenges with the common goal of advancing chiropractic. 

 

A major focus of the Summit is to improve practitioner participation, documentation, and compliance within the Medicare system. The article that follows below is the fifth in a series developed by the Chiropractic Summit Documentation Committee, and it focuses on Medicare audits. 

 

Near the end of the last article it was indicated that Contractors must evaluate suspected claims errors through the use of “Probe” reviews. You may refer to that article for background and insight. 

 

Under probe reviews, Contractors may initially examine 20–40 claims per provider for provider-specific problems. Contractors may also conduct widespread probe reviews (involving approximately 100 or more claims from multiple providers) when a larger problem, such as a spike in billing for a specific procedure, is identified. In either type of review, providers are notified that a probe review is being conducted and are asked to provide medical documentation for the claim(s) in question. Providers are then notified of the results of the probe review. 

 

When probe reviews verify that an error exists, the Contractor classifies the severity of the problem as minor, moderate, or significant. Contractors may classify the severity of the error by determining the provider-specific error rate (number of claims paid in error), dollar amounts improperly paid, and/or past billing history. All levels of error will require that providers receive education on proper billing procedures and the collection of money from claims paid in error. Contractors will then respond to the billing problem(s) as appropriate for the level of severity, and determine what steps need to be taken to correct the problem(s). 

 

Often, initial medical review (MR) is conducted by simply examining the claim itself, usually in an automated method. If more information is needed (a small percentage of cases), the Contractor will request access to medical records to confirm that the services rendered are reflected on the claim, coded correctly, and covered by Medicare. 

 

Validating initial findings from MR evaluations may require additional reviews resulting in corrective action. To assist in MR evaluations, CMS designed MR Progressive Correction Action (PCA). PCA ensures that MR activity is targeted at identified problem areas and that imposed corrective actions are appropriate to the severity of the infraction of Medicare rules and regulations. 

 

The following types of corrective actions can result from MR: 

 

Education— Problems detected at minor, moderate, or significant levels will require the Contractor to inform the provider of appropriate billing procedures. 

 

Prepayment review — Prepayment review involves MR of a claim prior to payment. 

 

Postpayment review — Postpayment review involves MR of a claim after payment has been made. 

Providers with identified problems submitting correct claims may be placed on “prepayment review,” in which a percentage of their claims are subjected to MR before payment can be authorized. Once providers have re-established the practice of billing correctly, they are removed from prepayment review.

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