Note that Palmetto GBA’s first letter does not request any records.
The Service-Specific Review Process
Palmetto’s system will randomly select for review claims containing the CPT code of the targeted service. (Additional services billed on the same claim that are not being monitored will continue to be processed.) Palmetto will then issue Additional Documentation Request (ADR) Letters to the practice, asking for medical information to substantiate each selected claim. Records should be submitted within 30 days of receiving the ADR Letter.
The MR Department will use the reviewed claims and medical records to calculate a charge denial rate (CDR), which determines the percentage of charges, if any, that have been billed in error. If they find an issue with your submitted claims, you may receive a Letter of Finds, which will ask you to participate in a corrective action plan. Once that plan in submitted, a second analysis will be completed at a later date.
Where to Go for Help
For additional information from Palmetto GBA, please refer to their Medical Review Progressive Corrective Action (PCA) Process website.
You should also review the new NCMS/PAI white paper, Medical Audits: What Physicians Need to Know, located on the NCMS Fraud & Abuse webpage. (Scroll to page 12 of the document for information on Service-Specific Probes.)
Finally, additional questions and developments can be directed to Kristin Freeman in the NCMS Member Resource Center at 919-833-3836 or email@example.com.
NCMS will continue monitoring this audit and will provide updates as we receive them.