HMSA reserves the right to audit claims and medical records submitted by participating providers to verify the accuracy of benefit payments made on behalf of HMSA members.
Determination of Overpayment
In some instances, it may be necessary for HMSA to determine if benefit overpayments have been made to a participating provider as a result of improperly submitted claims. Improperly submitted claims include, but are not limited to:
- Claims coded at a higher level of service than was provided (i.e., upcoding)
- Claims for services not medically appropriate for the diagnosis code(s) indicated.
- Claims for services not provided.
- Unbundled procedures billed on different claims.
To determine if overpayments have been made, HMSA begins by reviewing a valid random sampling of claims submitted by the provider. This method is used when large numbers of claims and records must be reviewed to determine benefit overpayments, but a claim-by-claim review is not feasible. HMSA follows the random sampling guidelines developed by the Centers for Medicare & Medicaid Services (CMS). In addition to the sampling, HMSA may request additional patient records from the provider.
Using the valid random samplings, HMSA determines whether the provider's claim submittals are appropriate or demonstrate a pattern of improper billings. Any benefit overpayment amount is calculated by projecting the findings of the valid random sampling to all of the provider's claims or services at issue.
HMSA recovers overpayments by deducting the appropriate amount from any benefit payments that may be due in the future to the provider.
The provider will be notified by HMSA of any benefit overpayment and will be given 30 days' notice that a deduction will be taken. The provider will be informed of the specific findings regarding the subject claims and any medical records reviews.
If the provider disagrees with the findings, he or she may file an appeal with HMSA using the dispute resolution process outlined in the HMSA Participating provider Agreement. The provider should submit a written request for review by an HMSA review committee within one year of the receipt of the notice of the findings. The administrative appeal and arbitration steps are also described in Appealing Processed Claims
