Navigating Prepayment Review
Steps for Your Practice to Emerge Successfully
Prepayment review—just hearing the term can cause a moment of panic for many medical practice administrators and physicians. But, with a proper understanding and approach, practices can navigate this challenging terrain successfully. In this blog post, we’ll delve into the reasons behind prepayment reviews and outline a comprehensive plan to help your practice emerge unscathed.
What is a Prepayment Review?
In simple terms, a prepayment review means that claims submitted to an insurance company are reviewed for accuracy and compliance before payment is issued. The aim is to ensure that the services billed are medically necessary, properly documented, and in compliance with the payer’s policies.
Why Does it Happen?
Prepayment reviews can be triggered for various reasons:
High billing volume of certain codes compared to peers.
Rapid increases in claim submissions.
Frequent changes in billing patterns.
Previous issues with improper payments or compliance.
Steps to Navigate Prepayment Review Successfully:
Stay Calm and Don’t Panic: Remember that not all prepayment reviews are the result of suspected wrongdoing. They can be routine or even random.
Understand the Scope: The first thing to do is determine what the review covers. Is it for all services or specific codes? Is it for all providers or just one?
Gather Documentation: Every claim under review will require supporting documentation. Ensure you have all the relevant medical records, notes, lab results, and any other pertinent information.
Review Your Claims: Before submitting, check claims for accuracy. Make sure that documentation supports the medical necessity of the billed service.
Engage with the Payer: Communication is crucial. Engage with your payer contact to clarify any doubts, seek guidance on what they specifically require, and understand the timeframe for the review.
Seek Expert Help: Consider getting an external audit by a healthcare compliance consultant or a healthcare attorney. They can provide insights into potential pitfalls and help you improve your documentation and billing practices.
Educate Your Staff: Ensure your billing team, providers, and other relevant staff are aware of the review. Train them on any identified issues and how to prevent them in the future.
Stay Organized: Keep a meticulous record of all correspondence, claims submitted, and documentation provided during the review period.
Respond Promptly: If the payer asks for additional information or documentation, provide it promptly. Delay can result in payment hold-ups.
Plan Financially: With funds potentially held during the review, it’s wise to have a financial contingency plan. This could be a reserve fund, a line of credit, or other financial strategies.
Review Outcomes: Once claims are processed, review the feedback. If there are denials, understand the reasons. This is a learning opportunity.
Appeal if Necessary: If you believe a claim was unjustly denied, be ready to file an appeal. Ensure you understand the appeal process for your payer.
Post-Review Actions:
Once the prepayment review is lifted:
Analyze the entire process for learning points.
Make necessary changes to your practice’s billing and documentation processes.
Consider regular internal audits to stay compliant.
Conclusion:
While a prepayment review can seem daunting, it’s important to remember that with the right approach and resources, it can be a learning and growth opportunity for your practice. The key lies in understanding the process, staying proactive, and continually striving for billing and documentation excellence.