Pre-Pay Audits Set Up for Two HIPPS Groupings.

Palmetto GBA recently announced new medical prepay audits based on certain HIPPS codes that have the highest denial rates. While PGBA internally identified the top 20 HIPPS groupings that have the highest denial rate, they have currently only published and set pre-pay audits up for the following two groupings:

  • 2CGK*
  • 1BGP*

As a provider, you should be prepared for possible ADRs on claims with these HIPPS. When an End of Episode claim is submitted using one of the two above HIPPS groupings, Palmetto GBA will place the claims into ADR status and you will be required to submit additional documentation from the chart in order for a determination to be made on the claim either being paid or denied. If you have limited time for QA activities, these are the charts you may want to focus on.

HEALTHCAREfirst providers that currently subscribe to Business Intelligence have the ability to track these claims using a new “At Risk Claims” view located in the Receivables Intelligence Product drop down menu. The view includes a listing of all episodes that will be audited upon EOE submission. Providers can monitor these claims as they go through the billing process.

Currently none of the other Medicare Administrative Contractors have announced similar HIPPS audits, however they are most likely on the horizon. To assist all providers, with preparing for potential upcoming audits, regardless of MAC, the At Risk Claim view also includes all claims that fall into the top 10 most denied HIPPS groupings based on all claims in the HEALTHCAREfirst database.

HEALTHCAREfirst will provide updates if Palmetto GBA publishes information on additional edits based on the other 18 HIPPS groupings they identified in their medical review.

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