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How do I get off prepayment review? / Q on starting a practice - what do I call you for?

Provided by:  Jennifer Kirschenbaum, Esq.
April 6, 2017
Question:

Jennifer, 

I am on prepayment review with a third party payor.  It is sucking the life out of my staff and I do not want to send out notes.  How do I get off? 

Thanks, 
Dr. O


Answer:

Doc, I feel for you.  Prepayment review is a process you have consented to as a contracted provider.  Unless the carrier is well outside its regular procedures, you are going to have to cooperate. Now, if you have submitted a representative sample of your services and documentation, and your documentation surpasses requirements for reimbursement, then you should no longer be on prepayment review.  Sometimes the carrier needs reminding of this and a little nudge to get you off review - sometimes, a lot of the time, your documentation isn't as great as you think it is, and until you make certain changes you may remain on flag. So, what to do now?  Well, you may need to engage counsel and bring on a certified coding expert to review your notes and help you make the necessary changes so you can easily receive payment on a going forward basis. We also may need to nudge the carrier from removing you from the review. 

We should discuss the specifics offline to better assess - what are you being reviewed for, which carrier, how many claims have you submitted, what's been requested and have you received/implemented education...  


Question:

Hi Jennifer, 

Thanks for Tuesday's email - Starting a Practice - specifically, what do I call you for?  

Thanks, 
Dr. S

Answer:

Good question!

I get involved with any and all of the following - 

 

Basically anything contractual and relationship based.  

Question:
Jennifer, 
I am on prepayment review with a third party payor.  It is sucking the life out of my staff and I do not want to send out notes.  How do I get off? 
Thanks, 
Dr. O
Answer:
Doc, I feel for you.  Prepayment review is a process you have consented to as a contracted provider.  Unless the carrier is well outside its regular procedures, you are going to have to cooperate. Now, if you have submitted a representative sample of your services and documentation, and your documentation surpasses requirements for reimbursement, then you should no longer be on prepayment review.  Sometimes the carrier needs reminding of this and a little nudge to get you off review - sometimes, a lot of the time, your documentation isn't as great as you think it is, and until you make certain changes you may remain on flag.    So, what to do now?  Well, you may need to engage counsel and bring on a certified coding expert to review your notes and help you make the necessary changes so you can easily receive payment on a going forward basis.    We also may need to nudge the carrier from removing you from the review. 
We should discuss the specifics offline to better assess - what are you being reviewed for, which carrier, how many claims have you submitted, what's been requested and have you received/implemented education...  
Question:
Hi Jennifer, 
Thanks for Tuesday's email - Starting a Practice - specifically, what do I call you for?  
Thanks, 
Dr. S
Answer:
Good question!
I get involved with any and all of the following - 
reviewing and helping you wrap up your lease or space purchase
forming your corporate entity
patient forms
hiring employees (background checks, contracts, offer letters, employee handbooks, training policies)
review loan documents (these are mostly standard, but happy to help if needed)
vendor contracts - review contract with biller, consultant, doctor employees, third party vendors 
Basically anything contractual and relationship based.  

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