Active FECA Bulletins (2001-2005)

 

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• 2003, 2001

 

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Fiscal Year 2003

Bulletin	Subject
FECA Bulletin No. 03-07	War Hazards Compensation Act (WHCA) Bulletins have been moved to their own location.

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Fiscal Year 2001

Bulletin	Subject
FECA Bulletin No. 01-10	Bill Pay/BPS - Sampling of Bills

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FECA BULLETIN NO. 01-10

Issue Date: April 30, 2001

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Expiration Date: April 29, 2002

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Subject: Bill Pay/BPS – Sampling of Bills

Background: The supervisory sampling of bills was initiated in 1994 (FECA Bulletin 94-10), with the enhancement to the Medical Bill Processing System. The procedure was reissued and updated in 1998 (FECA Bulletin 98-05) because of reports from the Office of the Inspector General citing numerous errors in bill processing and the finding in several accountability reviews that bill sampling was not being conducted in a number of district offices.

Results of the medical quality index introduced during the 2000 accountability reviews suggest that processing errors have decreased in number and indicate that bill sampling is routinely conducted in the district offices.

However, during the same period, multiple changes have occurred within the FECA program that impact on the bill sampling procedures. Implementation of the Correct Coding Initiative (CCI) increased the complexity of the automated editing and bill resolution decisions, as well as the need for accurate keying. Medical coding specialists have joined the staff in the district offices to resolve bills suspended for complex issues, to serve as medical provider liaisons, and to conduct quality assurance activities. Imaging of case information and medical bills in the district offices has altered some of the bill resolution manual processes.

This bulletin reviews and updates the bill sampling procedures to improve the probability of detecting significant errors and trends in bill processing, and to take into account the changes mentioned above.

Purpose: To transmit updated procedures for the sampling of bills.

Reference: FECA Bulletins 94-10 and 98-05.

Applicability: Regional Directors, District Directors, Fiscal Officers, Bill Payment Supervisors, Medical Coding Specialists, and appropriate National Office personnel.

Action:

1. The Medical Coding Specialist (MCS) will sample bills processed through the BPS on a monthly basis. The MCS will examine all the bills in the sample in accordance with the instructions in Attachment 1 and complete the Bill Sampling Worksheet.

2. By the tenth day of each quarter, the MCS will provide a report of the previous quarter's findings to the District Director. The report should include (a) the worksheet with the total number and percent of bills with errors and subtotals for each type of error, and (b) recommended corrective action(s).

3. A copy of the quarterly report (findings and corrective actions) will be provided to a designated National Office Medical Coding Specialist, no later than the 20th day of the quarter, along with a time table for corrective actions. The National Office Medical Coding Specialist will compile a national level report for management staff.

4. Each sample will be selected on an automated basis by the Monthly Bill Sampling OQS2 report and by retrieving DO information from a shared drive. The DO systems manager will import the case information into a sampling worksheet and route it to the MCS. The sample will comprise 32 line items that failed one or more of the following edits according to records in the b22 table: 301, 364, 371, 373, 375, 377, 708, 716, 738, 746, 758 and 766. Bills with bypass codes and bills paid using the AUTHO code will also be included. The sample should be composed of 69% edits, 25% bypass codes and 6% AUTHO codes. A back-up list will also be given to the MCS.

5. Separate batch sampling, as described in FECA Bulletin 98-05 is discontinued.

6. The Accountability Review and Management Review processes will verify that bill sampling is conducted in accordance with the above instructions and that corrective actions are implemented on timely basis.

 

Disposition: This Bulletin should be retained until incorporated into the Federal (FECA) Procedure Manual, or otherwise superseded.

 

DEBORAH B. SANFORD
Director for
Federal Employees' Compensation

Distribution: List No. 4--Folioviews Groups B and D
(All Supervisors, Fiscal Officers, Fiscal and Bill Pay Personnel, Systems Managers, and Technical Assistants)

 

Attachment 10-01

BILL SAMPLING INSTRUCTIONS:

1. For each bill in the sample, the MCS should obtain a Central history and an on-line history. The Central history contains receive date, payee address, authorizing initials and ineligible amounts and codes. The on-line history contains service dates, units, procedure codes, bypass codes, charge amounts and paid amounts, as well as data on denied bills and bills that reject in the Central processing. The BP040 reports will also be needed to obtain the payment address. Any information not available on these reports should be obtained through the Sequent database or by reviewing the physical case file.

2. The MCS receives the monthly bill sampling worksheet that includes all data elements: case file number, batch ID number, bill ID number, line item number, dates of service, failed edit, procedure or NDC code as applicable, and billed amount.

3. The MCS reviews the keying/initial processing of each bill in the sample by reviewing the following data elements and comparing the data in the automated history with the data as found on the bill:

a. Receive date
b. Date(s) of Service (DOS)
c. Procedure code
d. Modifier(s)
e. Units
f. If the bill was paid, is the address on the bill the same as the address paid?
g. If the bill was paid, was the correct provider selected (correct sequence number)?

The MCS introduces a check mark for every keying error found into the appropriate column in the Worksheet.

4. The MCS reviews the authorized amount initials. If the bill exceeded the maximum for the provider type, are the authorizing initials present on the bill? Are they in agreement with those in the system? Any error found in this process such as bills that exceed the DO provider maximum but that do not show authorizing initials, etc. is marked on the Worksheet.

Note: To complete this task, the MCS must have a list of the provider maxima in the local system.

5. The MCS reviews the amount charged. Are there any of the charge amounts on the bill different from the amounts on the history? If so, were changes made to the bill, and are the changes justified? Ineligible amount codes and amounts should be considered in this respect.

6. The MCS reviews the bills paid with the use of bypass codes. Was the bypass code correctly applied? If not, should another code have been used or was a bypass code necessary at all? Should the bill have been denied? Any misuse of a bypass code counts as an error.

7. The MCS reviews the use of the AUTHO code. This code is used only when necessary and where no existing CPT code is available and the bill, case file, or case notes show prior authorization of the procedure. When no such authorization exists or when there is no compelling reason for the use of the code, the MCS assigns an error in this category.

8. The MCS reviews adjudication decisions. When bills suspend for relationship edits, was the correct decision made with respect to the relationship of the service to the accepted condition(s)? Was an authorization given? Were the CCI edit suspensions properly resolved? Errors are assigned as warranted.

9. When the review is completed, the MCS totals the number and types of errors on the Worksheet, and analyzes results. The MCS communicates his/her findings and recommended corrective actions to supervisory personnel.

10. At the end of every quarter, the MCS prepares a formal report containing all the Worksheets, a narrative summary of findings, any recommended corrective actions with a suggested timetable, and a list of corrective actions from previous period that were completed during the quarter. He/she forwards this document to the appropriate supervisory personnel by the 10th day of the following quarter.

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