Monday, April 10, 2017

Medicare J5 MAC Announces Pre-Pay Audits for Rehab Ultra High RUGs in IA, KS, MO, NE, National

Dan Ciolek


On April 4, 2017, Wisconsin Physician Services Government Health Administrators (WPS GHA), a Medicare Administrative Contractor (MAC) for the Centers for Medicare and Medicaid Services (CMS), announced that they will be conducting prepayment service specific complex medical reviews of Inpatient SNF services for providers in the J5 Jurisdiction. 


The J5 Jurisdiction encompasses SNFs that submit claims from Iowa, Kansas, Missouri, Nebraska, and other national providers. 


The article states that “A prepay edit will be initiated with reason code 51SNF for J5 claims with dates of service on or after April 1, 2016, meeting the following criteria:

· Original inpatient claims
· Type of bill – 21X
· Containing ultra-high rehabilitation RUGs”


On the WPS GHA website, they state that use data analysis to identify services at risk for potential errors. When the data analysis supports the potential for high risk billing practices within a specific service, a prepayment edit is then initiated to identify potential errors or incorrect billing of the service. The goal of Medical Review is to reduce the claims payment error rate by identifying patterns of inappropriate billing through:

· Identifying patterns of inappropriate billing through data analysis

· Conducting medical review of claims

· Educating providers on identified issues


Please note that while WPS GHA is also the CMS MAC for the J8 Jurisdiction (which covers Indiana and Michigan), AHCA has confirmed that this new audit announcement only applies to providers that submit claims as J5 providers.


Contact dciolek@ahca.org if there are questions.

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