Learn more about our new process for auditing paid claims

Blue Cross Blue Shield of Michigan and Blue Care Network have partnered with HMS^® to conduct various audits of paid claims.

• For Blue Cross, HMS will conduct selective professional and nonhospital facility audits.
• For both Blue Cross and Blue Care Network, HMS will conduct the diagnostic-related group, or DRG, audits.
• Inpatient high-dollar audits will remain as they are.

Professional and nonhospital facility, and DRG audits are a retrospective review of paid claims. The review ensures that billed and paid services were ordered, medically necessary, documented and reported correctly. For these audits, medical records will be requested for review. Once the review has been completed, HMS will send the findings letter and information on how to request an appeal, if necessary.

For hospital, professional and nonhospital facility audits, the appeals process has been simplified to a two-step process:

• For automated billing and compliance audits, disputed claims will be eligible for a one-step internal appeal, and findings will be adjusted at the claim level.
• For complex, medical necessity audits, an independent external review is the second step in the appeal process. After the second level is completed, findings will be adjusted at the claim level.

For more information, refer to the Record article from January 2018 on commercial professional and facility claim audits. You can also refer to March and May 2018 Record articles defining the changes to provider audits and the new appeal time frames. The appeals process for DRG audits will remain the same.