Increased Claim Scrutiny!

Palmetto GBA is performing a variety of medical review activities in addition to the reviews discussed in the next article. As part of our normal medical review process, we perform ongoing data analysis and identify services and providers for medical review.

Providers selected for probe reviews would have approximately 20- 40 claims selected for medical review. Providers that have been progressed to complex medical review would have a percentage of their claims selected for medical review that is commensurate to their charge denial rate. For example, a provider with a 40% charge denial rate on a probe review would likely be progressed to complex review with their edit set to suspend 40% of the claims they bill for medical review. 
Providers that have questions or issues related to the volume of claims selected for medical review should contact the phone number listed in their notification letter.  Prepayment medical review is also being performed by the ZPICs. If a ZPIC is performing prepayment medical review of a provider, the ADR letters will be on Palmetto GBA letterhead but will identify that the documentation is being requested by and should be returned to the ZPIC.

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