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CMS Pushing to Reduce Improper Payments

James Carroll for HealthLeaders Media, November 17, 2011

For some, the initial reaction to the announcement of prepayment review may be unfavorable, but it should actually be a positive development for providers, says Kimberly Hoy, JD, CPC, director of Medicare and compliance for HCPro, Inc.

“Post-payment reviews are so far after the fact that hospitals aren’t able to resubmit claims with correct information or submit denied inpatient stays for payment on 12X type of bills and they lose payment all together,” she says. “With prepayment reviews, the denials should be timelier to the submission of the claim, which will help to improve providers’ ability to correct and submit claims within timely filing requirements.

"This allows providers to be paid for services within the regular claims processing, rather than having to appeal after the fact and possibly be awarded the difference in payment from what they were paid and what they should have been paid, which is what they have to do now," she continues.

From the provider standpoint, this may help to ease the administrative burden of the recovery audit process. One provider—a managed care contractor and RAC point of contact at a hospital in Region C, who wished to remain anonymous—says that this should help in the long run if it helps to prevent the recoupment process.

Read more on rebilling for Part B payments and prior authorization for certain medical equipment.

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