Administrative Memos

200106

FROM: Theodore O. Will, Chief Executive Officer
DATE: Oct 25, 2001
SUBJECT: Report of all Technical Denials Issued Related to Mandatory Review and PEPP Projects
IPRO CONTACTS:

Alice Vallar, Sr. Director, Medicare/Federal Health Care Assessment, Extension 423 and Kathy Terry, Ph.D., Sr. Director of Data Analysis & Evaluation, Medicare/Federal Health Care Assessment, Ext. 261

As you are aware, Medicare Mandatory Case Review and PEPP activities contract involve review/abstraction of hospital medical records. Accordingly, IPRO requests medical records from the hospitals who must provide them to IPRO within thirty (30) days of the date of IPRO's request, i.e., the "due date". When a medical record is not received at IPRO within this thirty (30) day timeframe, a technical denial must be issued by IPRO. The technical denial notice also alerts the fiscal intermediary (F.I.) to recover payment from the hospital for the dates of service for that medical record's episode of care based solely on the fact that the medical record was not provided by the due date.

Technical denials are considered payment errors because payment has been made for care that cannot be substantiated, i.e., lack of medical record documentation. In addition, hospitals experience negative fiscal impact when the F.I. recoups payments following technical denials.

The severity of this impact is related to the magnitude of lost reimbursement on each case as well as the volume of cases involved.

To assist your hospital in identifying the volume of cases which resulted in technical denials, IPRO has compiled and enclosed two hospital-specific reports. The report in Attachment I provide comparisons to your Hospital Peer Group and New York State in regard to technical denial rates. Attachment II provides a detailed hospital-specific case list of technical denials (both PEPP and Mandatory Review).

RECOMMENDATIONS:

Review hospital processes to identify root cause(s) for untimely submission of medical records.
Identify opportunities for improvement in medical record submission process to eliminate future technical denials.
Submit cases identified in Attachment II as "technical denials" to IPRO. A copy of IPRO's technical denial notice should be affixed as a cover letter to the medical record submitted. (Note: When the technical denial notice cannot be located, use the cover letter provided as Attachment III and affix a copy to each medical record provided.) If you have already submitted a medical record to reopen the Technical Denial, DO NOT RESUBMIT.

Should you have any questions, feel free to contact Dr. Kathy Terry in regard to data issues or Alice Vallar for case review issues.