Announcing updates to our Prepayment Utilization Review policy

Blue Cross Blue Shield of Michigan has updated its Prepayment Utilization Review policy. This policy update, which will become effective immediately, is as follows:

Prepayment Utilization Review

Prepayment Utilization Review, sometimes called PPUR, is a process we use to determine appropriate liability for covered health care services before paying claims for the services. We do this for a select group of providers who have been identified for medical record review before claims are paid.

Reasons for the review

We may recommend providers for PPUR for one or more reasons. These reasons may include the following:

• A provider is under investigation or review for possible improprieties, or has been indicted or charged with improprieties.

• A provider is under investigation or review by a regulatory board or agency involving the termination or suspension of licensure, certification, registration, certificate of need or accreditation.

• A provider demonstrates a pattern of noncompliance with our policies, guidelines and procedures.

• A provider fails to document the medical necessity for a significant number of services, following a final audit determination.

• A provider demonstrates a pattern of overutilizing or inappropriately billing.

• A provider is or has been departicipated.

• To ensure appropriate liability for services.

How the process works

Once a determination is made that a provider should be placed on PPUR, we notify that provider, in writing, of our determination.

The provider must include supporting documentation with each claim submitted so we can verify that each procedure billed was medically necessary and that the claim was billed properly. If the provider doesn’t comply with these procedures, the claim can’t be reviewed; it will be denied and returned to the provider.

In addition, providers who are placed on PPUR must develop a corrective action plan that addresses the issues identified as problematic. They must submit that plan for our review and approval. While the provider is on PPUR, we evaluate his or her adherence to the corrective action plan with the prospect of removing the provider from the PPUR process. The provider may meet with us to discuss the evaluation.

Providers are reviewed on a six-month basis. They may be removed from PPUR if they meet all of these requirements:

• They comply with their corrective action plan.
• They comply with all Blue Cross policies and procedures.
• They demonstrate a significant reduction in their error rate.

But a provider will remain on PPUR and may be subject to additional sanctions if he or she:

• Doesn’t demonstrate compliance with his or her corrective action plan.
• Fails to comply with Blue Cross policies and procedures.
• Doesn’t demonstrate a significant improvement in his or her error rate.