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Provider Specific Audits
These are audits generally referred to Prepay Medical Review by Postpay Medical Review as a result of a provider probe review. These providers have been notified by Postpay Medical Review of how they compare to their peers in the billing of specific
codes.
A probe is a medical review that is performed on a sample of claims for a particular procedure code. The review is followed by educational feedback to providers to help them correct problem areas. After the education is complete, a follow up data
analysis is done. If there is no significant improvement in billing patterns, the provider’s claims for that/those procedure code(s) are flagged for prepayment medical review. Sometimes a provider is put on prepay audit immediately following the
review, if error rate or dollars were real high. Providers placed on prepayment review are notified by letter and informed of the codes involved in the review. The audit specifications are made clear to the provider as well as the name of a contact
person.
The educational process continues in a progressive way during prepayment review with a periodic re-evaluation of progress. This may result in adjustments to the review process but the provider is always made aware of this.
Should a provider fail to take the corrective action after continued guidance and educational efforts, the provider may be referred to the PSC (Program Safeguard Contractor) as the next step in the Progressive Corrective Action process.
Privacy laws preclude posting of the specifics of these audits on the web site but those on provider specific audit are totally aware of the details. |
