Medical Review Strategy

Wisconsin Physicians Service (WPS) Medicare continues to be committed to supporting the reduction of the national paid claims error rate. At the same time, WPS Medicare will do its part to protect the national trust account for the citizens of this great nation. In an effort to support these goals, the WPS Medicare Medical Review (MR) Strategy will focus on initiatives that are intended to correct aberrant billing practices by the provider community. This approach will be consistent with recent mandates from the Centers for Medicare & Medicaid Services (CMS).

A WPS multi-disciplinary team comprised of management representatives from Medical Review, Medicare Central Data Unit (MCDU), Provider Outreach and Education (POE), Claims and Policy are instrumental in the development of the MR Strategy. During the strategy development stages, the team utilizes various sources as the impetus for the strategy. This team explores high level issues driven by data analysis, which may come from Comprehensive Error Rate Testing (CERT), the Office of the Inspector General (OIG), CMS, referrals, and other sources.

Providers for whom data analysis indicates a potentially significant billing issue may receive communication from Medical Review identifying the potential billing problem, as well as providing a Comparative Billing Report (CBR). The CBR will compare individual provider data to jurisdictional group data. The letter will present an opportunity for the provider to review the information and conduct a self-audit to identify any coverage or coding errors that may have occurred. If errors are identified, the provider may submit a corrected claim with the appropriate billing and/or, if necessary, submit a voluntary refund to WPS Medicare.

When data analysis indicates a significant billing or post provider communication monitoring reveals there has been no significant change in the individual provider's billing patterns, a provider specific probe review may be performed. In the event that it is deemed necessary to conduct a probe review, Medical Review will implement the following actions at its completion:

  • Provide findings of the probe review in a notification letter.
  • Include in the probe findings notification letter the name and contact information for a POE staff person who may be contacted for the purpose of follow-up education.
  • Provide additional post probe education through POE, if requested by the provider.

To address these widespread issues, Service-Specific reviews may be utilized to identify the most frequent coding and documentation problems. Those identified issues may be published on our Website prior to initiating Service-Specific probe reviews. The results of those reviews will allow for the development of tailored widespread E/M education. Only the general findings of the Service-Specific reviews will be published on the Website. No provider- specific information will be posted.

WPS Medicare believes that providers and suppliers want to correctly bill their services, and will do so if given the opportunity and proper education. To assist with this, Medical Review will provide support to POE's educational initiatives in the form of clinical expertise.

Medical Review, in partnership with POE, looks to achieve reduction in the national claims payment error rate through a combined effort of review and education.

Page Last Updated: Monday, 14-May-2012 12:02:14 CDT