CMS Targets Providers that Have High Error Rates in New Claims Processing, Fraud Reviews


CMS will focus only on providers and suppliers that have high claim error rates or billing practices that vary significantly from their peers.

To stop improper payment, prevent fraud and to be less of a burden on health systems that are processing claims correctly, the Centers for Medicare and Medicaid Services is now targeting for audits those providers and suppliers that have high error rates.

CMS said in the August 14 notice that it is directing its Medicare Administrative Contractors to focus their medical review on specific providers and suppliers within a service, rather than all providers and suppliers billing a particular service.

The contractors in the new Targeted Probe and Educate pilot will select claims for items and services that pose the greatest financial risk to the Medicare and those that have a high national error rate.

Previously, the first round of reviews included all providers for a specific service. The new claim selection is more provider- and supplier-specific.

This eliminates those providers who are, based on data analysis, already submitting compliant claims, CMS said.

Providers and suppliers with continued high error rates after three rounds of review may be subject to additional actions such as  100 percent prepay review, extrapolation or referral to a recovery auditor.

Providers and suppliers may be removed from the review process after any of the three rounds of probe review, if they demonstrate low error rates or sufficient improvement

The probe and educate initiative, launched in 2014, selected a limited number of claims from each Medicare provider for review. The contractors assessed the claims and educated providers on proper medical billing and fraud prevention strategies.

(Source: Susan Morse; Healthcare Finance News [8/22/2017])