Palmetto GBA Railroad Medicare is conducting fee-for-service medical review activities to protect the Medicare Trust Fund against inappropriate payments. Railroad Medicare is performing record reviews under several types of review processes:
- Traditional postpayment review based on service-specific codes where an Additional Documentation Request (ADR) is sent for a single claim on a specific code. The ADRs are for previously paid claims for a specific CPT/HCPCS code from random sampling of all claims related to the code.
- Postpayment review occurs when a reviewer makes a claim determination after the claim has been paid. Postpayment review results in either no change to the initial determination or a “revised determination” indicating that an overpayment or underpayment has occurred.
- Traditional prepayment reviews based on service-specific codes where an ADR is sent for a single claim on a specific code
- Prepayment review occurs when a reviewer makes a claim determination before claim payment has been made. Prepayment review always results in an “initial determination.”
- Targeted Probe and Educate (TPE) is a medical review process that focuses on provider-specific review of claims and provides education to providers billing these claims
- A provider will receive notice of inclusion in the TPE program and ADRs will be sent for code-specific claims. The ADR may request records for claims that have been previously paid or those that are still in process for payment.
- TPE cases that remained open and on pause during the Public Health Emergency(PHE) have been closed and letters were mailed on August 24, 2021, with notification to those providers. All providers chosen for TPE reviews will be entering an initial first round of TPE.
Summary of Review Types
When Palmetto GBA identifies a service as being at risk, the potential error is validated with a review. Conducting a review ensures that medical review activities are targeted at identified problem areas. The sample of potential problem claims is used to validate the hypothesis that such claims are being billed incorrectly or in error. You may view current service-specific reviews in the articles shown below.