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Mercy Care regularly reviews and analyzes claim handling practices to identify opportunities for improvement. Mercy Care currently utilizes Optum to assist us in this process. Mercy Care has expanded services with Optum to further enhance our prepay payment integrity program in accordance with expectations set forth by our Medicaid regulators.
Optum will be reviewing physician and facility claims to ensure that proper payment is being made in accordance with our contracts, national coding guidelines and nationally accepted billing guidelines. There are two new correct coding programs that will be deployed by Mercy Care: Orthonet and Claim Validation. The Orthonet program will ensure proper coding of complex surgical claims such as orthopedic or spinal surgery. This is a program that will compare the claim received from the provider against the medical record to validate the coding on the claim. Claims deemed to be incorrectly coded will be returned to the provider for correction prior to payment. Claim Validation will leverage a predictive model to identify claims that are potentially coded incorrectly. Once the claim is identified as requiring review, a medical record will be requested to validate the claim submitted by the provider. If the coding is determined to be inaccurate, the claim will be returned to the provider for correction prior to payment.
In compliance with the HIPAA Privacy Rule, Mercy Care has entered into a Business Associate Agreement (BAA) with the above-mentioned suppliers. The Privacy Rule allows a covered entity to share information with another covered entity’s business associate as if the request came from that other covered entity.
As always, don't hesitate to contact your Mercy Care Network Management Representative with any questions or comments. You can find this Notice and all other provider notices on our Mercy Care website.
Thanks for all you do!
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