There are 50 Shades of Grey in federal prepayment review.
I hate wishy-washy laws. If a law exists, in my mind, it should be specific. However, that is not always the case.
Let me give an example. Let’s take, for example, prepayment review (PPR).
In North Carolina and many other states, PPR is statutorily defined in a two-page-long statute. Here, is Statute 108C-7, and it says, in the pertinent part:
“The provider shall remain subject to the prepayment claims review process until the provider achieves three consecutive months with a minimum seventy percent clean claims rate, provided that the number of claims submitted per month is no less than fifty percent of the provider’s average monthly submission of Medicaid claims for the three-month period prior to the provider’s placement on prepayment review. If a provider does not submit any claims following placement on prepayment review in any given month, then the claims accuracy rating shall be zero percent for each month in which no claims were submitted. If the provider does not meet the seventy percent clean claims rate minimum requirement for three consecutive months within six months of being placed on prepayment claims review, the Department may implement sanctions, including termination…”
Juxtapose this to the federal regulations applicable to Medicare:
42 CFR 405.903 is a much terser regulation. It states that a contractor may select a claim(s) for prepayment review. In conducting PPR, a contractor may issue additional documentation requests to a provider. But the regulation does not specify how many, a percentage, or any time frame. I find the federal regulation to be underwhelming and non-specific.
The federal regulation also allows a provider to have 45 days to submit documentation unless good cause exists for the lateness, but the contractor conducting the PPR can decide if good cause exists. Remember, the state statute for PPR states that penalties will be wielded upon failure of PPR. In Medicare, PPR will result in an initial determination under section 405.920, which states:
“After a claim is filed with the appropriate contractor in the manner and form described in subpart C of part 424 of this chapter, the contractor must:
(a) Determine if the items and services furnished are covered or otherwise reimbursable under title XVIII of the Act;
(b) Determine any amounts payable and make payment accordingly; and
(c) Notify the parties to the initial determination of the determination in accordance with § 405.921.”
Notice that the federal regulation details much less, seemingly leaving much to the discretion of the contractor. There is no penalty mentioned; instead, the contractor is given complete authority to decide how to proceed.
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