Medical Records, Stat!

By Judy Zwick, HMS Vice President of Product Innovation

Most questions we receive regarding pre-pay clinical claim review involve prompt pay. They tend to come down to, “How can I complete a clinical claim review within prompt pay guidelines?”

So let’s first address prompt pay guidelines. Prompt pay guidelines are based on specific requirements of the program and/or a contract between the plan and the provider. The Centers for Medicaid and Medicare Services and most contracts do allow for additional timing when a claim requires review of documentation for a payment determination.

Plans are likely managing to multiple, different guidelines. We understand the complexities associated to the process. Incorporating a pre-pay clinical claim review to this process can seem complicated. Especially, when you consider the elements to audit: You’re selecting claims, requesting documentation, reviewing documentation, and applying claim dispositions – all within a timeframe to ensure compliancy with those applicable guidelines. 

But it’s not as difficult as you may think.

Let’s begin by walking through an example of a claims cycle and how the most standard clinical claim review process fits within that cycle. The clock starts when the claim is received. Once the claim is in a post-adjudication, pre-check-write status, the claim-targeting technology is executed. Upon completion of the targeting technology, the claim is either approved for payment or selected for a clinical claim review.

If the claim is approved for payment, this indicates there is not a probability of a finding. So the claim is released for payment, all within the prompt-pay guidelines. For those claims selected for a clinical claim review, the most standard process is for the claim to be pended – and running parallel to this activity, a request for additional documentation is submitted to the provider.

These activities occur within prompt pay guidelines. At this point in time, the clock stops until the additional documentation is received.

 Upon receipt of the additional documentation, the clock resets and the review is completed by a clinician or a coder, with a final recommendation of “pay,” “deny,” or “adjust” made. The review period and the final recommendation being applied to that claim all occur within prompt pay guidelines.

Now there are variances to the process. You may be a payer which requires the claim to deny for additional documentation versus a pended claim. Or you may have a guideline that requires the clock to restart versus reset. All of these factors can be customized specific to your prompt pay requirements.

So the message is you can complete a clinical claim review in a prospective environment and remain compliant with prompt pay guidelines. 

For more information about clinical claim reviews, visit hms.com.

HMS (NASDAQ: HMSY) provides the broadest range of cost containment solutions in healthcare to help payers improve performance. We deliver coordination of benefits, payment integrity, and data solutions to health plans, state agencies, federal programs, and employers. Using innovative technology and powerful data analytics, we prevent and recover improper payments related to fraud, waste, and abuse. As a result of our services, customers recoup billions of dollars every year and save billions more through the prevention of erroneous payments.

This article was created in collaboration with the sponsoring company and our sales and marketing team. The editorial team does not contribute.