Administrative Memos

200304

FROM: Theodore O. Will, Chief Executive Officer
DATE: May 07, 2003
SUBJECT: Review of Technical Denial Process Related to The Hospital Payment Monitoring Program (HPMP)
IPRO CONTACTS:

Kathy Terry, Ph.D., Senior Director, Medicare/Federal Health Care Assessment, 516-326-7767, Ext. 261

As you are aware, Hospital Payment Monitoring Program (HPMP) activities involve review/abstraction of hospital medical records. Accordingly, the Clinical Data Abstraction Center (CDAC) requests medical records from the hospitals who must provide them to CDAC within thirty (30) days of the date of their request, i.e., the "due date". When a medical record is not received at the CDAC within this thirty (30) day timeframe, a technical denial must be issued by IPRO. The technical denial notice also alerts the fiscal intermediary (F.I.) to recover payment from the hospital for the dates of service for that medical record's episode of care based solely on the fact that the medical record was not provided for review.

Technical denials are considered payment errors because payment has been made for care that cannot be substantiated, i.e., lack of medical record documentation. In addition, hospitals experience negative fiscal impact when the F.I. recoups payments following technical denials.

The severity of this impact is related to the magnitude of lost reimbursement on each case as well as the volume of cases involved.

Many hospitals in New York continue to receive technical denials in regard to CDAC requested cases. We are therefore reminding hospitals of the technical denial process and of the need to submit records to the CDAC in a timely fashion. Technical denials create unnecessary financial loss and result in additional work for us all. Please review the recommendations, which follow, in addition to submitting any outstanding technical denials that are identified in Attachment I. Please submit your records as soon as possible. Note that you will only receive Attachment I if you currently have outstanding technical denials as a result of a CDAC-HPMP request.

RECOMMENDATIONS:

Review hospital processes to identify root cause(s) for untimely submission of medical records.
Identify opportunities for improvement in your medical record submission process to eliminate future technical denials.
Submit cases identified in Attachment I as "technical denials" to IPRO. A copy of IPRO's case-specific technical denial notice should be affixed as a cover letter to the medical record submitted. Note: If the case-specific technical denial notice (that was previously sent to you) cannot be located, use the cover letter provided as Attachment II and affix a copy to each medical record. If you have already submitted a medical record to reopen the Technical Denial, DO NOT RESUBMIT.

Should you have any questions, feel free to contact Dr. Kathy Terry at 516-326-7767, extension 261.