HealthChoice payment integrity program begins in July

Posted on: 6/13/18

Oklahoma’s HealthChoice plan for state and education employees has contracted with Medical Audit & Review Services (MARS) for a retrospective payment integrity program.  

The post-payment reviews will audit claims for compliance with medical coding standards, including the National Correct Claims Initiative, the American Medical Association’s CPT Assistant, and AAPC/AHIMA coding guidelines. MARS will evaluate whether the codes on the bill correctly reflect the services documented in the medical record. In many cases, the codes included on a medical claim affect the payment amount. The medical necessity of the services will not be under review as part of these audits.

MARS is a subsidiary of MultiPlan, a New York-based company offering provider networks, data analysis, and payment integrity services. Staffing for MARS includes 14 board-certified physicians along with licensed nurses and certified coders.

The Employees Group Insurance Division (EGID), which operates HealthChoice, stressed that their agency will be very involved in this process, not just turning the program over to MARS. EGID will approve reviews of potential coding problems identified by MARS.

MARS tells EGID that typically only about two percent of claims reviewed are returned to their clients with findings, so EGID anticipates the vast majority of claims will not be selected for audit. Medical record requests will include detailed instructions on submitting the documentation.  

If a claim’s coding is found to be inappropriate, the facility will receive a notice of negative determination that will cite the coding sources MARS relied on in determining there was an error. This notice will include a request for overpayment recovery, and a notice of appeal rights.  Such appeals will be handled by HealthSCOPE Benefits, the third party administrator for HealthChoice claims.

Dates of service for HealthChoice claims beginning July 1, 2018 or later are subject to these reviews. The first requests for medical records from facilities will be made around October 2018. Claims from the first six months of 2018 are being used by MARS, EGID, and HealthSCOPE for testing the review process but without any collection of overpayments for noncompliant coding. Later this summer, MARS and EGID plan to offer provider education related to coding issues identified from the test data. (Rick Snyder)