The PTS is designed to assist with CMS’s overall goals of ensuring that Medicare contractors analyze provider compliance with Medicare coverage and coding rules, plus taking appropriate corrective action when providers are found to be “non-compliant.” This sounds generally reasonable. But when contemplating the Medicare appeal process, it is of interest and concern that the provider information within the PTS “should be shared” with the Administrative Law Judge (ALJ) when a provider appeals a medical review determination. CMS’s stated reason for the requirement to “share” information in the PTS with the ALJ is “to demonstrate (that) corrective actions have been taken by the contractor.” This is quite concerning because the information in the PTS might be unfairly prejudicial to the provider, and could cause the ALJ to decide a case unfavorably due to the review of information unrelated to a particular case being appealed. Therefore, providers participating in an Administrative Law Judge Hearing on a RAC or MAC denial should obtain copies of any PTS information provided to the ALJ. Once this information is obtained, it should be reviewed carefully to ensure accuracy and relevance to the case at issue.

So what kind of information about your hospital will be tracked?

CMS requires the PTS to be used to identify all individual providers and to track all contacts made as a result of corrective actions taken in response to identified problems such as eligibility issues, medical necessity issues and repeated “billing abusers” that frequently change the way they code their bills to their financial advantage.

The contacts tracked will include medical review notifications, telephone calls directly related to probe or complex reviews and referrals to Provider Outreach & Education (POE).

Contractors also are required to coordinate this information with the Program Safeguard Contractor Benefit Integrity Unit (PSC BI) to assure contacts are not in conflict with benefit integrity-related activities. The PTS should contain the date a provider is put on a provider-specific edit. Of note is the fact that the contractor is required to reassess all providers on medical review quarterly to determine whether the behavior has changed. The contractor will note the results of the quarterly assessment in the PTS.

A variety of interventions could be implemented by contractors to correct what are perceived as inappropriate behaviors. Contractors should use feedback and/or education as part of their intervention, and should make sure that administrative actions are commensurate with the seriousness of the problem identified after a limited probe is done to understand the nature and extent of each. CMS warns that serious problems will be dealt with using the most aggressive administrative actions available, such as 100 percent prepayment review, payment suspension and use of statistical sampling for overpayment estimation of claims. “Small and isolated” problems should be dealt with through provider notification or feedback, with re-evaluation after notification. And as always, any evidence of fraud could result in referral to the PSC BI for possible action.

The message for providers is to pay close attention to any and all “contact” made by any CMS contractor, whether it is notification, outreach, feedback or a “limited probe.” You do not want to be taken by surprise by the cumulative effect of the contacts – Big Brother is watching.

About the Author

Linda Fotheringill, Esq, is a founding member of Washington West, LLC, and is a nationally recognized expert on denial and appeals management. Ms. Fotheringill successfully assists hospitals across the country, overturning “hopeless”  denials and generating millions of dollars in otherwise lost revenue.

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