Post-Payment Review: The Next Wave of Reimbursement Hassles?
Medscape from WebMD recently highlighted an article from a trade magazine called Drug Benefit Trends that caught my eye. The title was "New Business Tactic of Retrospective Review Leads to Reversal of Paid Claims".
The article discussed the impact of a recent increase in post-payment reviews on reimbursement for mental health care, a service that is sometimes excluded from coverage or subject to extremely low caps in private health plans, as P&O services often are. The upshot of the article was that, now that behavioral medicine caregivers have become savvy at documenting medical necessity and obtaining the requisite prior approvals, some Managed Care Organizations are changing tactics and now applying retrospective reviews.
One example was Connecticut-based Oxford Health Plans, who reported contracted with a company named "Audit Review Service" to review claims paid as far back as 1997. In one example cited, based on a review of a sample of as few as thirty charts, the hired guns decided that $3000 in services did not have bullet-proof documentation. Extrapolating that "error rate" to all cases seen at that facility from 1997-2002, the insurer then demanded immediate return of more than $50,000 in prior reimbursements.
The author, Bruce Pomerantz, MD, concludes that such tactics are not cost-effective in the long run and will likely lead to a crisis in access to such health services when providers refuse to deal with insurers whose reimbursements is so unpredictable. An Editors' Note at the conclusion of the piece observed that, under pressure, Oxford recently agreed to return such refund amounts, settle claims about documentation errors, and to return copies of patient records.
It's possible this was just a "stray bullet" from an overzealous insurance company. But, it might also be the first shot in a barrage of bullets aimed at increasing insurance industry profits. We need to remain on alert in P&O, and stay vigilant for any evidence that such trends start affecting our patients too.
The entire article is posted online at www.medscape.com/viewarticle/472792.
|
|