Audits of Medicare Plus Blue^SM PPO durable medical equipment claims began Aug. 1

On Aug. 1, 2017, SCIO Health Analytics^®, an independent company working for Blue Cross Blue Shield of Michigan, began auditing Medicare Plus Blue^SM PPO claims for durable medical equipment.

The scope of the audit will be either claim-specific or project-based, and will ensure that billed and paid services were ordered, medically necessary, documented, reported and covered under the patient’s contract, according to Centers for Medicare & Medicaid Services guidelines. It applies to all providers who bill DME codes.

The audits will look back two years and confirm that you’ve properly documented requirements for:

• Equipment billed with inappropriate diagnosis code
• Purchase versus rental
• Multiple providers billing for same services
• Multiple purchases of same items
• Capitation arrangement with additional fee-for-service items
• Capped rental items

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

The purpose of provider audits is to:

• Confirm compliance with ICD-10 guidelines and diagnostic codes that are in effect on the date of service.
• Confirm compliance with CPT guidelines and codes.
• Confirm proper use of HCPCS codes.
• Detect, prevent and correct waste and abuse.
• Facilitate accurate claim payment.

Questions?

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