2013 Practitioner and Provider Manual - Presbyterian Healthcare ...

Fraud, Waste, and AbuseAll documentation required to justify the billingsmust be present in each file at the time of the audit.The time period selected for medical record reviewmay vary. Additions to the documentation or theproduction of missing chart notes or files at a laterdate cannot be accepted.Upon completion of the data-gathering portion ofthe audit, all of the information obtained isorganized and reviewed. Inquiries as to the resultsof the completed audit cannot be answered until allof the preliminary findings have been thoroughlyreviewed by the Presbyterian medical director andcompiled into a finalized Audit Findings Report. Thereport is sent to the provider through the U.S.Postal Service with a certified return receiptrequest.The report details the claim information such asmember name, date of service, CPT code, amountpaid, amount billed, and amount to be recovered, ifany. The Presbyterian claims or financial recoverydepartments handles all recovery requests.The provider or office representative is requested tosign, date, and indicate agreement or disagreementwith the audit findings within 30 calendar days fromdate of receipt of the certified findings letter. Theprovider options are the following:Agree with the audit.Disagree with the audit and provide additionalinformation/documentation.Disagree with the audit findings and waivehis/her right to an Administrative OfficerReview.Disagree with the audit findings and requestan informal Administrative Officer Review. Ifthe review option is chosen, the provider orrepresentative has the opportunity toparticipate either by attendance orteleconference to present their case. If theprovider waives the right to participate, theReview convenes to review the request andrender a decisionDuring the course of an investigation, many casesare found to be unintentional errors in which theprovider was unaware of the appropriate billingcriteria. In these instances, Presbyterian’s ProviderNetwork Management Department is available toassist the provider in rectifying the error andproviding education to prevent such errors in thefuture.Medical Identity Theft and IdentityMisrepresentation PreventionMedical identity theft occurs when someone uses aperson’s name and sometimes other parts of theiridentity such as insurance information without theperson’s knowledge or consent to obtain medicalservices or goods, or uses the person’s identityinformation to make false claims for medicalservices or goods. Medical identity theft frequentlyresults in erroneous entries being put into existingmedical records, and can involve the creation offictitious medical records in the victim’s name.Identity misrepresentation is the intentional use ofanother’s insurance card or the intentional “loaning”of an insurance card to an individual other than theenrolled member in order to access services.15-52014 Practitioner and Provider Manual - Ver. 3