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Removal from Medicare Prepayment Review

                  October 2, 2014

Question:

Jennifer,

I received a letter a few months ago that for most of the services I render I am not on Medicare prepayment review. I have not been paid by Medicare for these services since. What do I do?  

Please help.

Dr. K

Answer:

Prepayment review from any payor is terrible and can be practice ruining, Medicare in particular.  So to start, very sorry to hear.  In all likelihood you have been selected for review because of aberrant billing or documentation procedures.  You are likely still on prepayment review because your practices have not changed.  Its hard for the answer to this question to not be self-serving, because the first step you need to hear is its most likely time to hire a healthcare attorney.  Next, we work together potentially with your billing company or coding resource, or by seeking outside coding support, to organize our approach to addressing documentation deficiencies.  We do this systematically, by dissecting and applying the Local Coverage Determinations applicable to the services rendered.  We then address the contractor overseeing the prepayment review and argue our case.  Of course each practice is different and each issue presented is unique, but generally speaking, addressing prepayment review has a bit of a formula.  And, unfortunately, again, having an experienced healthcare attorney involved will likely expedite resolution dramatically, not to mention incorporate attorney-client privilege protection to your medical record review and communications.  

One of the big issues with prepayment review and properly extricating your practice from such review is the fact that you have no cash flow, so the concept of hiring an attorney and paying someone to help you collect money you do not have and believe you are validly owed may leave a bad taste in your mouth, however, without proper assistance you may be stuck in the denial, prepayment cycle indefinitely (or long enough to have trouble making payroll), and even scarier, without an idea of what the actual issues at hand are.  

To discuss a prepayment review initiated, contact Jennifer for an assessment on exposure and recommended next steps.  Initial phone consults for list serve members is free of charge.  


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