Any type of payer review can create some headaches for providers and cause problems for a healthcare office. Even for a practice that has taken administrative steps to try and prevent a prepayment review, it can still happen. A prepayment review means that you must include documentation WITH your claim. The payer will review that documentation BEFORE deciding if they will pay your claim. Reviews can take up to 30 days to determine if a claim will be paid. The result can be financially crippling to a practice, especially if one of their biggest payers puts them under prepayment review. So how should you respond when this happens to your practice?

First and foremost - do NOT ignore the problem. It will NOT go away on its own. If you continue to have a high claim error rate, it could lead to more than just a prepayment review. It could lead to a postpayment audit or even being added to an exclusion database. You don’t want it to get to that point so you must be proactive.

If the payer denies a claim, find out why! Carefully review the denial explanation and also review their policies. Policies vary between payers so you need to make sure that you know what they are looking for in the documentation. It is up to the provider to ensure that the patient record (documentation) is complete and also clearly indicates the medical necessity of the visit.

Considering that quite often the people reviewing your claim are not of your specialty, your documentation needs to ensure that there is no room for ‘guessing’ involved on the part of the reviewer. If they can’t see it right away, they aren’t going to go looking for the required information. They will simply deny your claim. Don’t make it easy for them.

Highlight key information that you want them to pay attention to and don’t be afraid to appeal their determination if you think that they are wrong. Use CPT guidelines, including CPT Assistant, and quote their own policies, where applicable, to support your appeal.

According to one legal firm, getting off prepayment review will require you to have a high percentage of error-free claims (e.g., 80%). The only way to do that is to make sure that your documentation is up to par and that you know the coding rules. The ChiroCode DeskBook includes comprehensive documentation information and also an “Audit Template” which can be used to assist you in conducting an audit of your own records to look for known problems.