MEDICARE SECONDARY PAYER HOSPITAL REVIEWS

The Hospital Intermediary Manual (Pub 10) was updated by revision 723 to reflect changes to the MSP Hospital Review process. This is a synopsis of the MSP Hospital Review process for those providers that have not been reviewed recently.

An MSP Hospital Review is a review of your MSP policies and practices to ensure that hospital procedures for admissions and claim submission comply with the law. Specifically, we will do an onsite review of admission and bill processing procedures.

Providers must supply the reviewer with complete files on all beneficiaries represented in the bill selected for review. For purposes of this review, a complete file should contain at least:

• A copy of the completed UB-92, also known as the HCFA-1450, or its facsimile;
• A copy of the admission questionnaire, or screen prints reflecting responses to the admission questions

Hospitals may be targeted for review for a variety of reasons including, but not limited to:

• Failure to develop MSP claims properly
• Failure to submit automobile accident cases
• Failure to report Credit Balances appropriately
• Failure to submit "no payment" bills, and
• Aberrant coding practices.

You will be notified in advance of the month's claims to be reviewed for onsite reviews. For example, if the onsite review will examine December bills, the intermediary will notify you no later than November 30 to permit you to segregate Medicare patient bills in advance. Therefore, onsite reviews will not take place during the same month as the month of the claims selected. If you are targeted for an onsite review, you will be contacted with all details.

Upon arrival, an entrance interview will take place with your admissions staff (including inpatient, outpatient, and emergency) to determine whether the hospital has established (1) policies to identify other payers, and (2) a system in which such policies are carried out in practice. During the interview, the reviewer will request a descriptive walk-through of your admissions process to observe an admission in progress.

The reviewer will determine whether your admissions questionnaire complies with the mandatory questions found at §301 of Pub. 10.

The reviewer will also conduct an entrance interview with your billing staff to determine whether you have established (1) policies on billing other payers; and (2) a system in which such policies are carried out in practice. The reviewer will also need a descriptive walk-through of the billing process.

The sample period will be determined by selecting the sample from one month of your claim submissions. Providers are expected to provide one month's claims to the reviewer, who selects the claim sample for onsite reviews.

The claim universe shall consist of Medicare inpatient, outpatient, and sub-unit claims (such as surgery or ESRD) for which a primary or secondary Medicare payment was made. The Intermediary will select the onsite claim sample using the following criteria:

• 2/3 or more inpatient claims, no more than 1/3 should consist of outpatient claims
• maximum of 60 claims and a minimum of 20 claims
• Medicare no-pay claims, and
• A mixture of claim types from your claim universe

The reviewer will compare completed MSP questionnaires and admission data with the selected claims. To accomplish this you must provide the reviewer with either completed inpatient and ER admission questionnaires, access to your on-line system, or screen prints from the on-line admission query systems for each Medicare beneficiary included in the claim sample.

A face to face exit interview will be conducted to advise the appropriate staff members of the review findings and recommendations.

After the reviewer has completed the investigation, a written assessment will be completed including selection criteria, the reviewer's findings, and suggested recommendations (if appropriate), as well as a list of the claims reviewed. The assessment will also include any discrepancies between your MSP policies and practices, and any innovations that you have devised to determine third party payer information. The Intermediary will forward a copy of the assessment to both the provider and to the regional office of The Centers for Medicare and Medicaid Services (CMS).

The assessment form will indicate whether any follow-up action is needed. If follow-up action is necessary, a reviewer will follow-up every 30 days until you have taken the appropriate corrective action, and will report any continued problems after three months to the CMS Regional Office MSP Coordinator. Unresolved problems may also lead to a subsequent audit or referral to the Fraud and Abuse unit.