Is your practice about to submit a red-flag claim?
Here's what new prepay edits will look for
It's hard to play a game if you don't know the rules. Accordingly, practices are more likely to file clean claims if they know what is considered appropriate. Here is a laundry list of items that will likely generate a red flag if HCFA implements its plan to adopt prepayment editing software developed by Atlanta-based HBO & Co.
According to HCFA, HBOC ClaimCheck software will initially focus on:
· procedure-to-procedure edits that search for claims that have been submitted for several procedures not normally performed together (estimated savings: $260 million annually);
· diagnosis-to-procedure edits that target claims for procedures that are "unexpected" given the diagnosis (estimated savings: $205 million annually).
HCFA hopes to sign a contract soon with HBO to give it enough time to have its ClaimCheck software installed in the computer systems of its Medicare's Part B carriers and running by fall.
The agency already has spent two years working with HBO's edit software in a small pilot program in Iowa. Because of this experience, which did produce a higher-than-average number of denials of Medicare claims for lack of medical necessity and improper code combinations, the agency wants to award a sole-source contract rather than put the project out for competitive bidding, which could add as much as a year to the launch date.
"I'm committed to making use of off-the-shelf products whenever possible and as quickly as possible," says HCFA administrator Nancy-Ann Min DeParle.
However, if provider groups are not satisfied with the progress of negotiations on giving providers details of why the ClaimCheck edits denied their claims, they could use the threat of forcing an open, competitive bidding process as leverage, say sources close to the process.
Besides seeing this an effective way to reduce overpayments, HCFA is anxious to install this software because of the recent heat it has taken from both Congress and the General Accounting Office. The criticism resulted from HCFA's resistance to buying commercial software over the past six years while trying unsuccessfully to develop its own in-house computerized edits.
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