October 5, 2017
Beginning January 5, 2018, Carewise Health, a Premera partner, will begin reaching out to some hospitals in our network to review patient bills, claim forms, and medical records. Carewise Health will contact hospitals on an on-going basis throughout the year. They’ll review bills offsite and occasionally review medical records onsite.
This audit is part of our overall assurance program to support accuracy of bills, claims and medical records.
What you need to know
Carewise Health may request copies of patient hospital bills and UB-04 claim forms for the initial off-site review of these documents, and if appropriate, to schedule an on-site review of selected medical records. Reviews are usually scheduled at least a month in advance.
Carewise Health may also request copies of medical records for off-site diagnosis-related group (DRG) validation audits. All DRG audits are performed by a Carewise Health coding specialist.
The audits may require more than one request for copies of patient hospital bills and medical records and possibly more than one on-site or off-site review of these records.
Carewise Health assigns highly skilled registered nurses (RNs) to audit hospital bills. During the on-site review, the RNs compare billed charges to medical records documentation to verify that services provided to Premera members are correctly ordered, documented, administered, and billed. The RNs also identify services or supplies not covered by the members’ contract, such as patient convenience items or investigational services, and review any charges related to the Premera Contract Exclusions/Disallowed Charges – Inpatient policy.
Overpayments
All facility-approved overpayments identified by Carewise Health will be sent to Calypso, the recovery department of Premera, to be offset against future payments.
HIPAA compliance
As Premera’s contracted business associate, Carewise Health is contractually required to comply with all Health Insurance Portability and Accountability Act (HIPAA) regulations. All contractual obligations between Premera and your facility regarding security and privacy of health information and access to that information are extended to Carewise Health.