|
Program Integrity and Payment Safeguard Services
HMS has assembled a team of very experienced medical review and coding professionals. This team is uniquely qualified to evaluate health care services for the purpose of confirming that providers have actually delivered the service(s) for which a claim has been submitted. HMS has experience with the review of all types of health claims, including inpatient, outpatient hospital, physician, and other claim types. Additionally, our personnel are very knowledgeable of the various payment methodologies (e.g., inpatient prospective payment systems, fee-for-service systems, and capitated payment systems, etc.) in use today. We assess the accuracy of the full spectrum of health care information submitted to payers by providers of health care services.
Past Performance:
HMS was recently awarded a contract with the Centers for Medicare & Medicaid Services (CMS) to serve as a Medical Record Review Contractor (MRRC) for the Medicare Advantage Risk Adjustment Data Validation (RADV) project for Payment Year 2007. With this project, HMS functions as both an “initial” and “second level” independent medical record review contractor. The role of the HMS Team is to identify discrepancies between diagnostic data submitted by Medicare Advantage Organizations (MAOs) to CMS, when documentation contained in the medical record is compared to the submitted data. Under the Medicare Advantage Program, capitation payments are “risk adjusted” based upon each patient’s diagnoses. Improperly submitting diagnoses can result in inflated payments to MAOs. HMS serves as the “initial reviewer” for some cases, and also serves as a “second validation reviewer” for certain other cases that were previously reviewed by another contractor, where discrepancies between submitted data and medical records were discovered.
In 2007, HMS was awarded a contract with the Centers for Medicare & Medicaid Services (CMS) to serve as the “Second Validation Contractor” (or SVC), related to CMS’ effort to confirm the accuracy of data submitted by Medicare Advantage Organizations (MAOs) to the Medicare Program. Under this contract, HMS focused on reviewing cases where another CMS contractor (the Initial Validation Contractor) had found suspected discrepancies between data submitted by MAOs and documentation contained in a patient’s medical record. The ultimate goal of this effort was to identify situations where improper payments had been made by Medicare, because erroneous data had been submitted by MAOs.
HMS is also involved in other program integrity activities, including the medical review of targeted services that were paid for by certain government health care programs. This effort is multi-state in scope and involves the review of services that have been identified, through claims data analysis, as being suspicious for possible waste, fraud, or abuse.
|
|