[Federal Register Volume 63, Number 250 (Wednesday, December 30, 1998)]
[Notices]
[Pages 71915-71916]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 98-34478]
-----------------------------------------------------------------------
DEPARTMENT OF DEFENSE
Office of the Secretary
Civilian Health and Medical Program of the Uniformed Services
(CHAMPUS); TRICARE Claimcheck Appeals
AGENCY: Office of the Secretary, DoD.
ACTION: Notice.
-----------------------------------------------------------------------
SUMMARY: This Notice sets forth the Department's plans for enhancing
the appeals process available to providers and beneficiaries for claims
determinations resulting from TRICARE Claimcheck coding logic.
ADDRESSES: TRICARE Management Activity, Medical Benefits and
Reimbursement Systems, 16401 E.
[[Page 71916]]
Centretch Parkway, Aurora, CO 80011-9043.
FOR FURTHER INFORMATION CONTACT: Stephen E. Isaacson, Office of the
Assistant Secretary of Defense (Health Affairs)/TRICARE Management
Activity, telephone (303) 676-3572, or Ann N. Fazzini, Office of the
Assistant Secretary of Defense (Health Affairs)/TRICARE Management
activity, telephone (303) 676-3803.
Background
Commercial claims-auditing software can be a critical tool in
addressing fraud and abuse, and commercial systems to detect
inappropriae coding/billing have been available for several years. Both
the General Accounting Office (GAO/AIMD-98-91), and the HHS Inspector
General noted the potential value of such systems as early as 1991. The
TRICARE Management Activity has taken a phased approach to
implementation of TRICARE Claimcheck, a customized version of the
commercially available HBOC/GPG ClaimCheck software.
TRICARE Claimcheck contains over 5 million edits that track appropriae
billing. These edits include unbundling incidental procedures, medical
visits, pre- and post-operative care, mutually exclusive procedures,
assistant surgeons, duplicate procedures, and age/sex conflicts.
Ninety-seven percent of claims pass through TRICARE Claimcheck aduits
without affecting reimbursement. TRICARE Claimcheck was first used in
May 1996, and subsequently has been linked with the start of the
TRICARE regional at-risk managed care support contracts. Prior to
implementation, there was a less-intensive review system that provided
only 246 rebundling edits as well as a list of about 250 procedures
taht were considered to be incidental to another procedure.
If TRICARE Claimcheck edits result in the denial or rebundling of
submitted procedure codes, providers may receive lower than expected
payments, and it is important that providers and beneficiaries have a
recourse. The General Accounting Office (GAO/HEHS-98-80) in its review
of TRICARE/CHAMPUS payments to physicians reported some provider
concern about the TRICARE Claimcheck system. Congress mandated that the
Department establish an appeals mechanism for providers and
beneficiaries in section 714 of the National Defense Authorization Act
for FY 1999. Rulemaking will be initiated to amend 32 CFR 199.10 to
address TRICARE Claimcheck appeals procedures. We are issuing this
Notice prior to rulemaking to explain the current appeals process and
to invite suggestions as to the form the intended TRICARE Claimcheck
appeals mechanism should take.
Current TRICARE Claimcheck appeals process: A TRICARE Claimcheck
appeal is an administrative review of auditing logic. The specific
dollar amount of an allowance (e.g., the CHAMPUS Maximum Allowable
Charge) is not formally appealable under TRICARE Claimcheck appeals or
the appeals procedures established in 32 CFR 199.10. TRICARE Claimcheck
appeals are made to the TRICARE Managed Care Support Contractor (MCSC)
that processed the claim. The MCSC recovers the claim and related
documents to completely review the case and verify the accuracy of the
application of the TRICARE Claimcheck edits. This process includes: (1)
verification of the correct procedure code(s) used; (2) review for
clerical errors that may have resulted in incorrect application of the
TRICARE Claimcheck edits; (3) medical review; (4) verification that all
necessary medical documentation has been submitted; and (5) review to
determine if medical circumstances existed that exceeded the expected
circumstances upon which the edit is based. A determination that allows
additional payment amounts results in an adjustment of the claim by the
contractor with no further action required by the beneficiary or
provider.
A corollary of the appeals process involves ongoing communications
with our MCSC Medical Directors, Lead Agent Medical Directors, and
professional societies and other organizations who have contacted the
TMA regarding the appropriateness of specific edits of TRICARE
Claimcheck. The TMA is working closely with these entities in reviewing
comments and comparing them to the clinical/medical rationale of the
TRICARE Claimcheck edit. When consistent with TRICARE policy, changes
are made in conjunction with the TRICARE Medical Director. This process
ensures that its edits do not result in improper denial or reduction of
payment. Suggestions are welcome regarding existing TRICARE Claimcheck
edits and recommendations for systemic changes to TRICARE Claimcheck.
Clinical/medical rationale for the suggested change should be included
for review of the recommendation by the TRICARE Medical Director.
Intended TRICARE Claimcheck appeals process; As stated above,
rulemaking will be initiated to further implement the Congressional
mandate for a more formalized TRICARE Claimcheck appeals process. In
cases where the current TRICARE Claimcheck appeals process described
above results in an adverse determination, providers and beneficiaries
will have a further level of appeal. Providers and beneficiaries will
be able to submit an appeal along with supporting documentation to the
TRICARE Management Activity. The requested for appeal will be
considered on its own merits and a written response will be provided
for each determination made. The appeal decision issued by the TRICARE
Management Activity will be the final agency decision on the appeal.
Dated: December 24, 1998.
L.M. Bynum,
Alternate OSD Federal Register Liaison Officer, Department of Defense.
[FR Doc. 98-34478 Filed 12-29-98; 8:45 am]
BILLING CODE 5000-04-M