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DRG & Short Stay Post Pay Audits

Date: 04/01/21

In an ongoing effort to ensure high quality claims processing and payment, Ambetter from Arizona Complete Health (Ambetter) is taking additional steps to verify the accuracy of payments made to our contracted facilities.  Beginning on May 1, 2021, Ambetter will begin auditing selected inpatient claims and associated medical records. Utilizing physician clinical judgment and nationally recognized guidelines there will be a review of the medical record to verify payment accuracy, and in some cases whether the admission should have been billed as an outpatient claim rather than an inpatient admission.  

Cotiviti is a Business Associate of Ambetter as defined in 45 CFR, Section 160.103 of the Health Insurance Portability and Accountability Act of 1996 (“HIPAA”) and will perform its responsibilities on behalf of Ambetter in full compliance with HIPAA requirements. Consistent with this business relationship and our contract with you, we request your assistance in providing Cotiviti with the information necessary to complete these reviews to the same extent Ambetter staff would be allowed.  

What to expect:

  1. Certain claims will be identified for post-payment audit based on standard clinical or correct coding criteria. For short stay or place of service audits, the reviews are supported by the following CMS regulations:
    1. “For inpatient acute IPPS hospital claims, review of the medical record must indicate that hospital care was medically necessary, reasonable and appropriate for the diagnosis and condition of the beneficiary at any time during the stay, and that the stay was appropriate for inpatient payment.” CMS Internet-Only Manual (IOM), Publication 100-08, Medicare Program Integrity Manual (PIM), Chapter 6, § 6.5.2, effective 06-13-2017.
    2. "Inpatient care rather than outpatient care is required only if the beneficiary's medical condition, safety, or health would be significantly and directly threatened if care provided was [sic] provided in a less intensive setting."  CMS Internet-Only Manual (IOM), Publication 100-08, Medicare Program Integrity Manual (PIM), Chapter 6, § 6.5.2.
    3. "A physician order has no presumptive weight.” “A physician’s order will be evaluated in the context of the evidence in the medical record.” Code of Federal Regulations, Title 42 § 412.46(b). These reviews are also supported by Medicaid Regulations in many states.
  2. If a claim is identified for audit, your Medical Records Department will receive a letter requesting medical records for specific paid claims and allowing 30 calendar days to get the medical records to Cotiviti.
  3. If records are not received, you will receive a second/final notice. If records are not received within 15 calendar days from the date of the second notice, an administrative denial and recovery of the original payment by Ambetter may occur.
  4. Should the review of the medical records result in an overpayment finding, you will receive an Audit Determination letter from Cotiviti explaining the results of the audit.
  5. If you disagree, you may submit a request for a second review with supporting information to Cotiviti within 30 calendar days. You may also submit a Formal Grievance or Appeal with Ambetter as described in the Explanation of Payment and Provider Manual.
  6. If you do not respond, we’ll assume you agree and Ambetter will proceed with a payment adjustment. However you may still submit a Formal Grievance or Appeal with Ambetter as described in the Explanation of Payment and Provider Manual.

Thank you for your assistance in this process.
Please contact our Provider Engagement team AzCHProviderEngagement@azcompletehealth.com if you have questions.