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You May Also Click Here For The Medicare.gov Glossary Of Terms.

Aberrancy

Services and/or providers identified through data analysis that appear outside of the peer norms.  As a contractor, Highmark Medicare Services must investigate to determine if the aberrancy represents an unacceptable practice or potential error. Highmark Medicare Services is required to further investigate the provider(s) and/or procedure(s) identified and implement timely and effective corrective action to protect the Medicare Trust Fund.

Actual Overpayment

An actual overpayment is the sum of payments (service by service) made to a provider for services that were determined to be medically unnecessary, not covered or incorrectly billed. (See also extrapolated overpayment)

Advance Beneficiary Notice (ABN)

When you believe Medicare will deny a service as not reasonable and necessary or too frequent, an advance written notice to the beneficiary can protect you from liability.

The provisions on advance notice are only effective when the advance notices are in writing, signed by the beneficiary, and dated. In cases where you elect to use advance written notices, you must use the modifier GA. The use of the GA modifier will indicate that an advance written notification was provided and signed by the beneficiary.

Ancillary procedure code

A procedure code other than the primary (or designated) procedure code(s) that was identified as one of the parameters of a review. All procedure codes other than the designated procedure code(s) are considered ancillary procedure codes.  When a designated procedure code is denied, all directly related ancillary services may be denied.

Additional Documentation Request (ADR)

When contractors cannot make coverage or coding determination based upon the information on the claim and its attachments (i.e., medical review audit), the contractors may solicit additional documentation from the provider by issuing an Additional Documentation Request (ADR).  ADR requests can be in writing or telephonically.

Automated prepay review

When prepayment review is automated, decisions are made at the system level, using electronic information, without the intervention of contractor personnel.

Carrier Medical Director (CMD)

A physician who is hired by the contractor to act as a resource and consultant.

Clinical Practice Guidelines

Reports/publications written by professional experts who have carefully studied whether a treatment works and which patients are most likely to benefit.  Also known as Community Standards of Practice. In the absence of national or local medical policies, clinical practice or community standards of practice may used to assist in the making a determination on a claim.

Complex Prepayment/Postpayment Review

Any in-depth review of a claim and any attachments, including the specific evaluation of medical records and any other supporting documentation. This review type requires professional medical expertise, at a minimum, a LPN.

Comprehensive Error Rate Testing (CERT)

A CMS program that audits Medicare claims to ensure the correct adjudication of claims billed to Medicare.

Consent

A post pay provider-specific case that involves the review of a selected sample of beneficiary's claims for the identified designated procedure code(s) and ancillary services within a specified time frame for a provider. Based on the review results, the overpayment may be extrapolated to the universe of beneficiaries.

Corrective Action

(See Progressive Corrective Action)

Data analysis

Data analysis is an essential first step in determining whether patterns of claims submission and payment indicate potential problems. Data analysis is the comparison of claim information and other related data to identify potential errors and/or potential fraud by claim characteristics (e.g., diagnoses, procedures, providers, or beneficiaries) individually or in the aggregate. Data analysis is an integrated, on-going component of MR activities.

Designated procedure code

A procedure code that was identified as one of the parameters of the review and/or the primary code that was identified as aberrant. A review may have one or more designated procedure codes.

Extrapolation

Extrapolation involves statistics to estimate or infer the overpayment on the basis of certain variables within the known range (sample), from which the estimated value (universe) is assumed to follow. Medical Review uses extrapolation to determine the overpayment for consent and full-scale cases.

Extrapolated Overpayment

The actual overpayment as determined by a review of medical records for selected claims times the number of beneficiaries in the provider's universe.  This is an estimated overpayment amount.

Fraud and Abuse

Fraud: the intentional deception or misrepresentation that an individual knows to be false or does not believe to be true and makes, knowing that the deception could result in some unauthorized benefit to himself/herself or some other person. The most frequent kind of fraud arises from a false statement or misrepresentation made, or caused to be made, that is material to entitlement or payment under the Medicare program. The violator may be a provider, a beneficiary, or an employee of a provider or some other person or business entity, including a billing service.

Abuse: the incidents or practices of providers that are inconsistent with accepted sound medical practice. Abuse may directly or indirectly result in unnecessary costs to the program, improper reimbursement, or program reimbursement for services that fail to meet professionally recognized standards of care or which are medically unnecessary. The type of abuse to which Medicare is most vulnerable is overutilization of medical and health care services.

Limited Probe

A sample of claims (not to exceed 20-40 claims) that are identified systematically for a specific provider to validate the hypotheses that such claims are being billed in error. A limited probe can be conducted on a pre or postpayment basis, and may result in further corrective action depending upon the probe review findings.

Local Coverage Determination (LCD)

LCDs are "local" Medicare coverage decisions created by Medicare Contractors in absence of specific statutes, regulation, or national coverage, or as an adjunct to national coverage.  A LCD defines if a service is covered and under what specific clinical circumstances the service is "reasonable, necessary, and appropriate."

Medical Necessary

Services or supplies that:

are proper and needed for the diagnosis or treatment of your medical condition;

are used for the diagnosis, direct care, and treatment of your medical condition;

meet the standards of good medical practice in the local community; and

are not mainly for the convenience of you or your doctor.

Medical Review Timeliness Requirement

For record requests that are received with in the 45-day time frame (or extended time frame when approved), contractors must complete the claims review and notify the provider and beneficiary, if indicated, within 60 days of receiving the last medical record.

Medicare Coverage

Whether or not Medicare covers a service may be based upon the following:

·         Benefit Category /Social Security Act

·         Statutory Exclusions

·         National Coverage Decisions

·         CMS directives and regulations

·         LMRPs /Reasonable and Necessary

Non-covered (Not-covered) services

Non-covered services are those for which there is no benefit category are statutorily excluded (other than § 1862 (A)(1)(a)), or are not reasonable and necessary under § 1862 (A)(1)(a).

Not Otherwise Coded (NOC)

CPT codes that end in the numbers "99". Used for services that cannot be coded with existing CPT codes.  A short description of the service must be documented on the 1500 claim form or narrative or supporting medical record documentation.

Options:

Option 1 - As a result of a consent review the provider selects the option to repay the extrapolated overpayment and gives up the right to appeal the decision.

Option 2 - As a result of a consent review the provider selects the option to submit additional documentation an/or have a meeting. With this selection the provider gives up the right to appeal the final determinations. Integral to this selection is the guarantee that the overpayment will not exceed the initial extrapolated overpayment following the re-review process.

Option 3 - As either the result of selection or by default if no selection is made to the consent results letter the provider is requested to pay the actual overpayment determined by the sample records reviewed in the consent case. The provider maintains his appeal rights; however, a SVRS case is initiated. (See SVRS)

Postpayment Review

Postpayment medical review of claims requires that a benefit category, statutory exclusion, reasonable and necessary, and/or coding determination be made AFTER claim payment.

Program Safeguards Contractor (PSC)

The PSC is a contractor dedicated to a specific statement of work (sow) under program integrity. This scope of work can be specific or general, and a limited or long-term commitment. Examples of PSC work includes Benefit Integrity and CERT. The term 'full PSC' is used to refer to any PSC tasked with prepayment medical review responsibilities in relation to requirements surrounding 'CERT' reviews.

Provider-Specific Review

A review conducted to validate potential problem claims for a specific provider.  Reviews can be conducted on a prepayment and/or postpayment basis.

Prepayment Review

Prepayment medical review of claims requires that a benefit category, statutory exclusion, reasonable and necessary, and/or coding determination be made BEFORE claim payment.

Probe Review

A sample of claims (prepayment or postpayment) chosen for review to investigate or validate the existance of a potential problem.

Progressive Corrective Action (PCA)

A concept designed by CMS for Medicare contractors to use when deploying resources and tools to conduct medical reviews. Data analysis is the first step in PCA to determine aberrancies in billing patterns that might suggest improper billing or payment. Validating the hypothesis of the data analysis is the next step. Before assigning significant resources to examine claims identified as potential problems, a probe review is conducted. The probe review results in the classification of the problem. The three (3) classification levels are minor, moderate, or major. If a minor problem is detected, MR will educate the provider on appropriate billing procedures and pursue recoupment of claims paid in error. If a moderate problem is detected, MR will educate the provider on appropriate billing procedures, will pursue recoupment of claims paid in error, and will initiate a subsequent corrective action (e.g., reprobe, prepayment provider review) until the provider has demonstrated correction of his/her billing procedures. If a major problem is detected, MR will educate the provider on appropriate billing procedures, pursue recoupment of claims paid in error, and will initiate subsequent corrective action (e.g., any combination of prepayment provider review, consent/statistical valid random sample cases, payment suspension, and/or referral to The Pennsylvania Benefit Integrity Support Center (PENN-BISC), when appropriate).

NOTE: PCA requirements do NOT apply when fraud development is initiated.

Provider Site Review

A review of medical records conducted at the provider's office etc.   When potential problems exist in multiple areas, contractors may conduct "team" reviews.  The team may consist of staff from MR, provider enrollment, etc. depending on the problems identified.

Rebuttal Statement

For postpayment reviews: within 15 calendar days of notification of results, each provider may submit a rebuttal statement.  The rebuttal statement and any additional documentation or evidence must be submitted within 15 working days from the date of the notification letter.   The provider's rebuttal statement should address why the recovery should not be put in to effect on the date specified in the notification letter.

Reprobe Review

A follow up review of an additional sample of claims (prepayment or postpayment) to determine if corrective actions were taken as a result of the initial probe review.

Re-Review

Re-reviews are conducted six (6) months after a consent or SVRS review or they are conducted 60-90 days after the finalization of a provider-specific review, if warranted.  The need for re-review is based on the errors identified and the error rate in a provider-specific review.

The re-review can be either a statistical review comparing the review period Ultra statistics to current Ultra statistics, or a mini-record review (5 claims per designated procedure code). The type of re-review is determined by the issue and whether or not the statistics indicate that the provider has corrected the aberrant billing practice.

Routine Prepayment/Postpayment Review

Routine review requires the intervention of specially trained Medical Review (MR) staff.  Routine review requires hands-on review of the claim and/or any attachment submitted by the provider (other than medical records) and/or claims history file and/or internal MR guidelines.  This type of review does not require review by clinical staff.

Sample

The claims that are systematically identified for review.

Service Specific Review

A review conducted to validate potential problem claims for a specific procedure code(s).   Reviews can be conducted on a prepay and/or postpay basis. 

Statistically Valid Random Sample (SVRS)

A method of review that permits Medicare carriers to create and review a random sample of beneficiary's claims instead of requiring a complete review of every claim for the period being examined. This sample is then used as a basis for determining the amount of overpayment for the universe.

Statutory Authority

The statutory authority for the MR program rests in the following sections of the Social Security Act (the Act):

Section 1833 (e) states "no payments shall be made to any provider unless it has formulated such information as the secretary may request in order to determine the amounts due such provider."

Section 1842 (2)(B) requires contractors to apply "safeguards against unnecessary utilization of services furnished by providers";

Section 1862(a)(1)(A) states no Medicare payment shall be made for items or services that "are not reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member " ;

The remainder of Section 1862(a) describes all statutory exclusions from coverage; and

Section 1861 and 1835 describes the Medicare benefit categories.

Statutory Exclusion

In order to be covered under Medicare, a service must not be excluded by title XVIII of the Act, other than by § 1862 (a) (1).

Third Party Development

Medical Review normally develops to the billing provider for medical records needed for post pay or prepay review. When claims are submitted to Medical Review that involve third party validations (e.g., lab, ambulance, etc.), Medical Review may develop to the third party involved (e.g., hospital, nursing home, dialysis facility, etc.) in order to obtain supporting medical records to validate the medical necessity of the services being billed to Medicare.

Ultra

A utilization trending, reporting, and analysis tool. This tool generates a report on provider specific data with a procedure code comparison to the provider's peer group.

Universe

The universe of beneficiaries is identified in both consent and SVRS cases. The universe is defined by the criteria supplied by the requester and may include any number of procedure codes, modifiers, etc. The request will also include the desired dates of service and finalized dates, as well as anything else that is crucial for defining the universe. These factors, along with the necessary provider (or supplier) information, will provide the foundation for identifying the universe. The universe will be constructed systematically by a data analyst from the claims processing data using the time parameters outlined in the request.

Waiver of Liability

A legal removal of an individual's responsibility to pay for a service when you believe Medicare will deny a service as not reasonable and necessary or too frequent, an advance written notice to the beneficiary can protect you from liability.

In accordance with Section 1879 of the Social Security Act, when assigned services are denied because they are determined to be not reasonable and necessary, the Medicare program makes payment when neither the beneficiary or the physician knew, and could not reasonably be expected to have known, that the services were not reasonable and necessary based on Medicare guidelines.

When the beneficiary did not have such knowledge, but the physician or supplier knew the liability for the charges for the denied service rests with the physician or supplier. When the beneficiary knew or could have been expected to know that the services were excluded, the liability rests withthe beneficiary.

Widespread Probe

A service specific sample of 100 claims that are identified systematically to validate the hypotheses that such claims are being billed in error.  A widespread probe can be conducted on a pre or postpayment basis, and may result in further corrective action depending on the probe review findings.