Medical Audit & Review Solutions (MARS) is currently conducting inpatient DRG retrospective audits on behalf of Mercy Care Plan (MCP) and Mercy Maricopa Integrated Care (Mercy Maricopa).
A conference call has been scheduled for you to discuss further detail on August 10, 2017 at 1:00 p.m. (Arizona time). Your Provider Relations Representative will be sending you an invite to this conference call. MARS representatives will be attending this conference call to assist with any questions you may have.
Background:
Mercy Care Plan is responsible for ensuring that federal and state funds are used efficiently, in compliance with all applicable regulations and guidelines. In addition to concurrent review of hospital admissions, the recent institution of the inpatient case rates has prompted MCP to take steps to identify incorrect payment associated with short stay admissions. It has been established that individuals with certain medical conditions are candidates for management via outpatient observation. In such cases the medical record must demonstrate that inpatient admission, rather than outpatient observation, was warranted based on specific concerns identified at the time of admission. The MCP and Mercy Maricopa audit program serves to ensure that hospital admissions qualify for inpatient status despite hospital discharge with 1 day. Also, select hospital stays of 2-3 days may be selected for audit to evaluate potential for outpatient management in lieu of inpatient admission.
Frequency of Audit: Monthly
MCP and Mercy Maricopa's current audit plan calls for routine monthly audits of the medical necessity of some inpatient admissions. You may or may not receive chart requests as part of future monthly audits depending upon the results of ongoing data analysis and utilization patterns.
Recovery Look-Back Period: 6 months
MCP and Mercy Maricopa follow the AHCCCS process which allows for recoup of claim payments within 12 months of a claim's date of service and claim resubmission within 12 months of the original claim paid date. The look back period of 6 months has been designed to accommodate this time frame by initiating audits within 6 months of payment to ensure timely completion and distribution of the findings.
Chart Request Time Period: 45-days from the date of the request letter
MCP and Mercy Maricopa's policy will allow providers up to 45-days from the date on the chart request letter to submit medical charts.
Chart Request Limits: 50 charts per hospital per audit period
MCP and Mercy Maricopa are currently limiting the number of records requested to 50 per provider during an audit period unless MCP and Mercy Maricopa finds reason (e.g. high error rates) to request a higher volume of charts for specific providers.
Missing Medical Charts: Deny full payment
MCP and Mercy Maricopa's provider contract language defines standards for maintenance of medical records. MCP and Mercy Maricopa will deny full payment if a provider is not able to submit the medical documentation required to support payment.
Auditor Qualifications: Independent physician review for medical necessity issues and independent certified coder review for coding issues
MCP and Mercy Maricopa will contract with an independent third-party to perform recovery audits. MCP requires physician review for medical necessity issues and certified coder review for coding issues. MCP requires that the independent reviewers meet Aetna's standards for background checks and qualifications.
Audit Results Response Time: 60 days from receipt of documentation
MCP and Mercy Maricopa will provide audit results within 60-days of the date charts are received. MCP and Mercy Maricopa will provide individual, written case result reports for every case necessitating a payment adjustment based on the audit findings.
Appeals Process: Appeals process as defined in the MCP contract or regulated Medicaid appeals process for providers
MCP and Mercy Maricopa will offer all providers the opportunity for claim reconsideration after audit results are issued. Providers may submit written supporting documentation to MARS for reconsideration within 30 days of the audit results.
MARS will provide a written response to the reconsideration within 30 days of receipt of supporting documentation.
Only after reconsideration does the formal Medicaid appeals procedure begin, which will be handled directly by the MCP and Mercy Maricopa Appeals department.
Payment Adjustments: Rebilling will be allowed for outpatient ancillary services
When overpayments are identified in the audit, MCP and Mercy Maricopa will retract the full payment amount but allow the provider to rebill for appropriate ancillary services. The provider will have 60 days from the date of the last audit results letter to submit a corrected bill.
Payment Adjustment Timing: Earlier of adjustment at the time of rebill or 60 days from the date of the last audit results letter
MCP and Mercy Maricopa will adjust for under or overpayments at the time of receipt of a corrected claim. If a corrected claim is not received within the indicated 60-day timeframe from the last audit results letter, MCP will initiate recoupment for outstanding overpayments.
