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September 2017

Audits of Medicare Plus BlueSM PPO outpatient, observation, ambulatory claims have begun

SCIO Health Analytics®, an independent company working for Blue Cross and Blue Shield of Michigan, started auditing Medicare Plus BlueSM PPO outpatient, observation and ambulatory payment classification claims on Aug. 1. These audits will:

  • Include a two-year look-back at claims.
  • Confirm medical necessity and compliance.
  • Detect, prevent and correct waste and abuse.
  • Facilitate correct claim payment.

Be ready to share medical charts for review. After an audit, SCIO will send you a letter with findings and information on how you can request an appeal, if necessary.

Outpatient hospital and facility audits
These audits will confirm correct billing of revenue, CPT and HCPCS codes, as well as modifiers and units.

Observation audits
These audits will confirm that claims include the following, as appropriate:

  • Medical necessity of an observation room
  • Patient discharge from emergency room, and not placed in observation status
  • Patient admission as an inpatient, and not placed in observation status
  • No other service needed with active monitoring
  • Time spent in observation, greater than eight hours
  • Time spent performing services

Also, the Centers for Medicare & Medicaid Services requires that hospitals and critical- access hospitals give the Medicare Outpatient Observation Notice form to beneficiaries receiving outpatient observation services for more than 24 hours. SCIO will look for:

  • Proper MOON form usage
  • Accurate completion of the form
  • A copy of the form in the member’s medical record

Ambulatory payment classification
These audits will review medical records to:

  • Evaluate coding accuracy
  • Ensure proper documentation of services


Questions?

  • Contact your Blue Cross provider consultant.
  • During an audit, if you need to speak to a SCIO vendor representative, call 1-866-628-3488.

No portion of this publication may be copied without the express written permission of Blue Cross Blue Shield of Michigan, except that BCBSM participating health care providers may make copies for their personal use. In no event may any portion of this publication be copied or reprinted and used for commercial purposes by any party other than BCBSM.

*CPT codes, descriptions and two-digit numeric modifiers only are copyright 2016 American Medical Association. All rights reserved.
Blue Cross Blue Shield of Michigan and Blue Care Network are nonprofit corporations and
independent licensees of the Blue Cross and Blue Shield Association.