Region B: Starting education in Michigan April 2. No feel for initial letter requests…Region C Starting ed in SC 3/19. will follow with FL and TX…Region D  Starting ed in Nevada, Utah and Arizona in March. Will use established “Black and white ” issues to begin with (automated recoupment)…All agree that rea activity of requests will begin in May.


Q:  How will medical Neceessity reviews be determined?  Region D:  Vanilla-  just like statement of work Certified coders and 1medical director.  Will self audit their own results..RegionC   Same + internal review board on global issues.
Region B  Same, no news. Region A  1 medical director, 2 alternate medical directors..35 member physician board.

Q;  What clinical screening tools will you use? Region D  We will use InterQual and Milliman as screening tools as guides.  Region C  We have not decided which clinical standards we will use.
Region B  We use InterQual.  CMS does not endorse any particular tool. Region A   Will use Milliman!!!!!!!!!!!!!!!!!!

Q: Can you comment on your customer services. Region .B  Excellent.  Promises open door. Region C  Exceptional. Region A  (Its getting deep in here.)  We overstaff our projects to limit wait times.
Region D:  Great team.  Over 15 years healthcare experience on average.

Qs from the floor….
Q:  Education – how will you do this? Group – through hospital associations.  We are forbiden to provide education to providers. Q: How do we define “new issues” that have to be reviewed by CMS? All issues, even those that came to light in the demonsttartion project, must go through the “new issue” review.
Q: Subcontractors?  Region C Viant is only subcontractor. Region A  We are responsible for all activities but we have the most subcontractors (3)  Region B PRG Schultz is only subcontractor.  Region D PRG Schultz is the only subcontractor.
Q:  Will contact information be customized on day 1? A: Yes.Forms will be introduced during outreach education. Go to for region B sign up. Solicitation of information will go to hospitals’ Compliance Officers
Q:When will websites be ready. This requires CMS approval and will be up during the summer.

Q:How do you make coding decisions?  Coders can disagree. A: Region C  Make suer your coders are current and certified. Region D  We funnell specialties (like orthopaedics) to coders in that specialty
Q:  WIll you link hospital claims to doctors claims  (like observation.)
A:  Group Yes.
Q: Will hysicians be involved in every medical necessity decision. Group:  No.  That is not a CMS requiremen
Q:How will you handle the volume of calls and appeals?  A: Region A We anticipate the volume.  Our strategy is to make sure that everything is so “clean” that there won’t be much room to appeal.!!!!!!!!!!!!!!!!!!

Share This Article