Indiana Prepayment Review

1. August 2007 1 Indiana Prepayment Review Presented by Emily M. Martin, R.H.I.A. Indiana SUR Manager

2. August 2007 2 Prepayment Review (PPR) PPR is a monitoring system utilized by the Indiana Health Coverage Programs (IHCP) to ensure that services are reasonable, medically necessary, and of optimum quality and quantity.

3. August 2007 3 405 IAC 1-1-6 (f) PPR of claims is not a sanction and is not subject to appeal.

4. August 2007 4 Why is a Provider Placed on PPR? Serious billing errors that show consistent lack of knowledge of IHCP rules, or lack of desire to abide by those rules. Relationship to other providers already placed on program.

5. August 2007 5 Provider Placed on PPR As the result of a SUR Audit. Referral from the Medicaid Fraud Control Unit (MFCU). Referral from the Office of Medicaid Policy and Planning (OMPP). Referral from Program Integrity (PI).

6. August 2007 6 PPR Timeline Providers are placed on PPR for a minimum of six (6) months. Providers receive a monthly claim denial report�claim/line item specific denial reason. Compliance Reviews.

7. August 2007 7 PPR Notification PPR Notification Letter and PPR Criteria Letter sent to provider. Outlines PPR requirements and timelines With Finding Letter Separate if placed on immediate PPR

8. August 2007 8 Claim Submission Process Provider to submit claim and all supporting documentation to the fiscal agent (EDS). Claim receives an ICN and is then suspended to PPR for review. PPR of claim is completed within 60 calendar days of ICN assignment.

9. August 2007 9 PPR Process Claim is adjudicated by a PPR Reviewer. The claim (ICN, DOS, RID, claim decision) is placed into the SUR database by the PPR Support Specialist. Each month a Claim Denial Report is sent to the provider with claim/line item specific denial information.

10. August 2007 10 Indiana PPR Team 1 Full Time PPR Coordinator Compliance Reviews Administrative Reviews PPR Notification & Criteria Letters Provider Contact Monthly Claim Denial Report Quarterly and Annual PPR Reports 1 Full Time PPR Reviewer & .5 PPR Reviewer Adjudicate PPR Claims

11. August 2007 11 Indiana PPR PPR claim adjudication volume grew by 32% in 2006, increasing from 6,123 claims in 2005 to 8,987 in 2006. This contributed to $828,388.66 in savings to the IHCP in 2006, an increase of 13.5% from 2005.

12. August 2007 12 Indiana PPR Claims Adjudicated

13. August 2007 13 Indiana PPR Providers

14. August 2007 14 Indiana PPR 2006

15. August 2007 15 Potential Savings 2005 � 2007 YTD There are 15 providers who have not submitted claims since their implementation on PPR. This has contributed to a potential savings of $4,531,179.41 to the IHCP.

16. August 2007 16 Common DME Denials No physician order. No proof of delivery. Item billed does not match item ordered i.e. brief vs. pull-on. Total quantity billed exceeds quantity ordered. Date billed does not match date delivered.

17. August 2007 17 Common Chiropractic Denials Insufficient documentation to support services rendered. Able to verify # regions. No indication that the x-ray services were completed in/by the physician�s office. The claim was for x-ray services that were billed for both technical and professional components (billed with no modifier). Since only the interpretation was provided (professional component) a modifier must be applied. Manual therapy codes can not be billed with manipulation codes on the same body region on the same date of service.

18. August 2007 18 Common Dental Denials Panoramic or full mouth x-rays are limited to once every three years. Sealants are once per lifetime. Sealants previously placed on 0/0/0000. Comprehensive exam limited to one (1), per lifetime, per recipient, per provider. Extraction previously billed.

19. August 2007 19 Common Transportation Denials Documentation submitted does not support quantity of�miles billed. Documentation submitted does not support the�transportation of an attendant. Documentation submitted�supports one way trip. Documentation submitted does not support the wait time billed.

20. August 2007 20 General Denials Insufficient documentation to support code billed. Prior authorization not received for the items billed. Documentation submitted does not support the level of CPT billed. Illegible documentation for the date of service billed.

21. August 2007 21 General Denials Duplicate claim. Documentation submitted does not match the date of service billed. Documentation has been modified when compared to the previous claim submissions. Altering documentation could be viewed as attempting to obtain payment inappropriately.

22. August 2007 22 Common Education Documentation is not authenticated. Any claims received after date of service 0/0/0000 without appropriate notation will be subject to denial by PPR. When a member is unable to sign for services rendered, the documentation must include the reason for the member�s inability to sign and the relationship to the patient of the person signing.

23. August 2007 23 Common Education Late entries should be noted as such, dated, and initialed so that it is not mistaken for altered documentation. Physician order must be signed and dated by the ordering physician. Any future claims received without appropriate notation will be subject to denial by PPR.�

24. August 2007 24 Common Education Delivery ticket must contain a full item description (including item size and/or packaging) in order to confirm items delivered match items billed. Any future claims received without appropriate notation will be subject to denial by PPR.

25. August 2007 25 Questions?