Palmetto GBA conducts probe reviews on services provided by Medicare providers within Jurisdiction 11. These reviews are in an effort to prevent inappropriate payments. Data analysis is performed at regular intervals to determine the types of services or providers that will be subject to review. Based on the results of the data analysis, edits are set up in the system to select claims for a probe review, which is either service-specific or provider-specific.
For service-specific probe reviews, a sample of 100 claims will be selected. Based on the results of the data analysis, more than one service-specific review may be conducted at the same time. The total number of claims selected for provider-specific reviews is between 20 and 40 for each provider identified for review. Providers selected for the probe review will receive a letter from Palmetto GBA explaining the reason for the review, why the provider was selected, and the type of review being conducted.
The number of claims selected on a daily basis for each provider is based on the number of claims received from the provider in a given day. Palmetto GBA will randomly select a sample of claims meeting the review criteria each day for each provider until the total number of claims needed to satisfy the probe sampling has been reached. However, providers are cautioned not to alter their billing practices to reduce the number of claims selected for Additional Documentation Request (ADR). If this is identified, it may result in additional medical review, referral to other review entities and or extrapolated overpayments.
When a claim is selected for review, an ADR letter is sent to the provider. It is possible that providers may receive an ADR prior to receiving their probe notification letter if they were selected for a provider-specific probe review. Providers should also note that in the past, medical ADRs were mailed in yellow envelopes. ADRs are now mailed in white Palmetto GBA envelopes, so providers should ensure that internal office processes are set up to identify these requests.
Part A and home health and hospice providers may also use the Direct Data Entry (DDE) system to monitor which claim(s) are in the ADR status/location S B6001. To view claims in DDE that were selected for ADR:
- Select menu option 01 ‘inquiries’. Press enter and select 12 for ‘Claims’ at the sub-menu.
- Press enter. Tab to the S/LOC field and type SB6001.
- All claims in this S/LOC will be reflected in the ‘Claim Summary Inquiry’ screen
Providers may also print their ADR letters from DDE rather than waiting for the hard copy to arrive in the mail. To print a copy of the letter after accessing the list of claims following the above instructions:
- Tab to a specific claim and type an ‘S’ in the ‘SEL’ field;
- Once in the claim, press page forward – the ADR will appear after the claim on page 6
In accordance with Medicare regulations, providers have 30 days to respond to an ADR. Providers may fax the records to the number listed in the ADR or mail the records to the address provided in the letter. If no response to the ADR is received within the specified timeframe, payment on the claim will be denied. Palmetto GBA has up to 60 days from the date the documentation is received to complete a review and make a determination on the claim. Once a determination is made, the processing of the claim will be finalized.
Every effort will be made to move providers through the ADR process as quickly as possible. Providers that need to contact the Medical Review (MR) department related to the review of their medical records can call (803) 763-7491. Before calling the MR department regarding significant financial hardships, providers should have responded to some of their ADRs in order for the MR department to provide feedback.
The Medical Review telephone line is a voice messaging system. Providers should ensure that they leave a contact name and telephone number, their provider number, NPI and a brief message to explain the reason for the call. The MR Department will return calls within two business days of receipt in the order the calls are received. Making repeated calls to the MR department is not necessary.
For info or tips on Homecare Billing, contact Imark Consulting, Inc. at 888-370-3339 or visit us at www.homehealthbilling.com