Wis. ForwardHealth Online Handbook, Hospice, Topic #22798

The PIR (Payment Integrity Review) program:

• Allows the OIG (Office of the Inspector General) to review claims prior to payment.

• Requires providers to submit all required documentation to support approval and payment of PIR-selected claims.

The goal of the PIR program is to further safeguard the integrity of Wisconsin DHS (Department of Health Services)-administered

public assistance programs, such as BadgerCare Plus and Wisconsin Medicaid, from fraud, waste, and abuse by:

• Proactively reviewing claims prior to payment to ensure federal and state requirements are met.

• Providing enhanced, compliance-based technical assistance to meet the specific needs of providers.

• Increasing the monitoring of benefit and service areas that are at high risk for fraud, waste, and abuse.

Fraud, waste, and abuse includes the potential overutilization of services or other practices that directly or indirectly result in

unnecessary program costs, such as:

• Billing for items or services that were not rendered.

• Incorrect or excessive billing of CPT (Current Procedural Terminology) or HCPCS (Healthcare Common Procedure

Coding System) procedure codes.

• Unit errors, duplicate charges, and redundant charges.

• Billing for services outside of the provider specialty.

• Insufficient documentation in the medical record to support the charges billed.

• Lack of medical necessity or noncovered services.

Note: Review of claims in the PIR process does not preclude claims from future post-payment audits or review.

Payment Integrity Review Program Overview

When a provider submits a claim electronically via the ForwardHealth Portal, the system will display a message if the claim is

subject to PIR. The message will instruct providers to submit supporting documentation with the claim. Providers have seven days

to attach documentation to claims. The claim will automatically be denied if documentation is not attached within seven days.

Claims that meet PIR requirements may be eligible for payment once they are accurate and complete. Claims that do not meet

PIR requirements may be denied or repriced. In these cases, providers are encouraged to:

• Review the EOB (Explanation of Benefits) for billing errors.

• Refer to the Online Handbook for claims documentation and program policy requirements.

• Correct the PIR billing errors and resubmit the claim.

Types of Payment Integrity Review

There are three types of review in the PIR program:

• Claims Review

• Pre-Payment Review

• Intermediate Sanctions

For each type of review, providers must submit supporting documentation that substantiates the CPT and/or HCPCS procedure

codes on the claim.

Claims Review Pre-Payment Review Intermediate Sanction

How claims are selected for

review

A sampling of claims is

selected from providers,

provider types, benefit areas,

or service codes identified by

the OIG.

The OIG has reasonable

suspicion that a provider is

violating program rules.

The OIG has established cause

that a provider is violating

program rules.

How providers are notified

that selected claims are

under review

The provider receives a

message on the Portal.

The provider receives a

Provider Notification letter and

message on the Portal.

The provider receives a Notice

of Intermediate Sanction letter

and message on the Portal.

How to successfully exit the

review

Claims are selected for review

based on a pre-determined

percentage of claim

submissions of specific criteria.

75% of a provider's reviewed

claims over a three-month

period must be paid as

submitted. The number of

The provider must meet

parameters set during the

sanction process.

Claims Review

In accordance with Wis. Admin. Code § DHS 107.02(2), the OIG may identify providers, provider types, benefit areas, or

procedure codes, and based on those criteria, choose a sampling of claims to review prior to payment. When a claim submitted

through the Portal that meets one of these criteria is selected for review, a message will appear on the Portal to notify the provider

that the claim must be submitted with all necessary supporting documentation within seven calendar days. The claim will

automatically be denied if documentation is not attached within seven days.

Pre-Payment Review

In accordance with Wis. Admin Code § DHS 106.11, if the OIG has cause to suspect that a provider is prescribing or providing

services that are not necessary for members, are in excess of the medical needs of members, or do not conform to applicable

professional practice standards, the provider's claims may be subject to review prior to payment. Providers who are subject to

this type of review will receive a Pre-Payment Review Initial Notice letter, explaining that the OIG has identified billing practice or

program integrity concerns in the provider's claims that warrant the review. This notice details the steps the provider must follow

to substantiate their claims and the length of time their claims will be subject to review. Additionally, a message will appear on the

Portal when the provider submits claims to notify the provider that certain claims must be submitted with all necessary supporting

documentation within seven calendar days. The claim will automatically be denied if documentation is not attached within seven

days.

For a provider to be considered for removal from pre-payment review, both of the following conditions must be met:

• 75% of the provider's reviewed claims over a three-month period are approved to be paid.

• The number of claims the provider submits during that three-month period may not drop more than 10% from their

submitted claim amount prior to pre-payment review.

The OIG reserves the right to adjust these thresholds according to the facts of the case.

Intermediate Sanction Review

In accordance with Wis. Admin. Code § DHS 106.08(3)(d), if the OIG has established cause that a provider is violating program

rules, the OIG may impose an intermediate sanction that requires the provider's claims to be reviewed prior to payment. Providers

who are subject to this type of review will be sent an official Intermediate Sanction Notice letter from the OIG that details the

program integrity concerns that warrant the sanction, the length of time the sanction will apply, and the provider's right to appeal

the sanction. The provider also will receive a message on the Portal when submitting claims that indicates certain claims must be

submitted with the necessary supporting documentation within seven calendar days. The claim will automatically be denied if

documentation is not attached within seven days.

For a provider to be considered for removal from an intermediate sanction, the provider must meet the parameters set during the

sanction process.