Proposed rule would speed appeal process

Telephone appeals may be instituted

If you decide to challenge a claim denial, remember that the Health Care Financing Administra tion in Baltimore has proposed new rules for speeding the process by instituting a telephone appeals procedure.

Under the HCFA rule change, providers, patients, suppliers, and carriers can challenge Medicare Part B initial claim determinations by telephone. Currently, claim appeals and responses must be submitted in writing and filed with HCFA and the carrier.

After its initial decision, the carrier must give the provider — or anther party — six months to request a review of the action. Upon the provider’s request, this initial review period can be extended an additional six months.

Under HCFA’s new rule, the current review time frames still stand. However, both providers and carriers have the option of asking for a decision review by telephone.

Knowing the different kinds of audits Medicare conducts and what auditors tend to look for in each one can help when a claim is denied or you learn your practice has been selected for review. The most basic kinds of audits are:

1. Electronic claim submission review.

This is a common low-level audit in which Medicare will send you a letter asking for a sample of up to 10 patient charts. Generally, federal auditors are looking to see if:

— dates indicating when the patient was treated and when services were provided match;

— all the appropriate authorizations have been checked off and physician identification numbers are correct;

— adequate and proper documentation exists that the service being billed was indeed performed and appropriate.

Even if you clear those hurdles, other potential problems might be found later with such things as coding discrepancies and evaluation and management documentation. With any audit, it is important to send along any and all information referred to in your claim, such as patient histories and medication lists.

2. Focused review.

Focused reviews generally are launched when the auditor’s computer system notices a provider is billing an unusually large number of claims for a particular code or set of codes. Basically, Medi care wants to know why this is happening and will ask for up to eight charts for review.

If Medicare concludes there may be a problem, it will send you a letter noting a deviation in your billing patterns and give you six months or so to change things. Once that happens, you are put on Provider Audit List (PAL). Being placed on the PAL automatically increases the odds of your becoming the subject of a comprehensive medical review audit.

3. Comprehensive medical review.

If you are targeted for a comprehensive review, Medicare will take a close look at the charts of 15 or more of your patients — including tests, labs, evaluation and management services, and billing of preventive services as covered services — over the past six months, searching for any possible questionable or actual overpayments.

If the examiners determine you owe Medicare a refund, you have these options:

• Write a check and go back to work.

• Question the finding and gather additional documentation backing your position.

• Request a statistically valid sampling, which will mean gathering and subjecting to an audit several hundred patient charts for each physician in question.

Before you take any action, be sure to consult your lawyer.