13_TCRS_Sec_J_Atch_J-3_Smpl_Init_Rnds_Test_Rpt.pdf

Attachment J-3 Sample Initial Readiness Test Report

TCRS HT9402-17-R-0002, Section J, Attachment J-3 Page 1 of 4

Department of Defense – Defense Health Agency

Comprehensive Readiness Test January 23 – February 01, 20XX

Initial Report

TCRS HT9402-17-R-0002, Section J, Attachment J-3 Page 2 of 4

I. BACKGROUND

A comprehensive readiness test of (Contractor Name) claims review operations under the TRICARE Claims Review Services (HT9402-15-R-0000) contract was conducted by the Defense Health Agency (DHA) – Aurora, Improper Payment Evaluation & Transition Section (IPE&TS) of the Budget and Resource Management Division (B&RMD). The readiness test was conducted from (dates of test) at the (contractor location) claims auditing facility(ies) located in (city, state of facility location) and at the DHA office in Aurora, Colorado.

The team traveling to (city and state) was made up of (number of team members and team members names and office locations(for those who travel). (Team members name), all from TMA, reviewed claims output at TRICARE Aurora.

On Wednesday, January 23, 2013, a brief entrance conference was conducted with (contractor name), and DHA. During the entrance conference, the scope of the test, the number and order of test claims to be processed and the administration of the readiness test were discussed. The readiness test was comprised of (number of test scenarios) institutional and non-institutional medical, dental and pharmacy claims.

On Friday, February 01, 2013, an exit meeting was held with (contractor name), and DHA to discuss the initial readiness test findings.

II. READINESS TEST DESIGN

A. Data Management

A Microsoft Access database was designed to manage the provider, beneficiary and test scenario data used to create hospital, physician, dental and pharmacy claim forms, explanation of benefit forms from other health insurance, and authorizations and referrals.

B. Claims

This comprehensive readiness test was designed to test claims auding functions for the TCRS contract. A total of (number) test claims were created by the DHA-Aurora staff, using the database as a data management tool. The (#) test claims were submitted to the contractor to review.

The readiness test claims were designed to test (contractor’s name) ability to correctly audit claims, and involved a variety of test conditions to include validating the accuracy of claims processing which included: authorizations and referrals; eligibility; enrollments/dis-enrollments; covered and non-covered benefits; identification of missing claims information; claims processing jurisdiction;

preventive care benefits; calculating cost-shares/co-payments, deductibles and catastrophic cap amounts;

reimbursement calculations; laboratory and radiology services; third party liability (TPL) procedures;

TRICARE reimbursement systems (i.e. outpatient prospective payment system (OPPS), Diagnosis Related Group (DRG), etc.); identifying duplicate claims; and other health insurance (OHI) calculations.

Upon completion of claim evaluations of test claims by the (contractor name), the readiness team evaluated each claim and the contractors review determinations to determine (1) if the claim was reviewed correctly, and (2) whether the expected result of the test condition had been met.

Claims which were reviewed correctly and met the test condition’s expected result were scored as “passes”. Claims failing the test conditions or which contained other compliance review errors were

TCRS HT9402-17-R-0002, Section J, Attachment J-3 Page 3 of 4 scored as “fails”. Each “fail” was presented to (contractor name) for review and concurrence or disagreement. Those claims which the readiness team determined had “failed” are detailed in the attached report.

(Contractor name) was instructed that initial review actions of all test claims should be completed by (day, month, year) and rebuttal reviews completed by (day, month, year). All initial review and rebuttal review actions were completed well within the timeframes.

III. INITIAL READINESS TEST RESULTS

A. CLAIMS

Of the 200 test claims, 193 (96.5%) passed and 7 (3.5%) failed. The details of the specific errors for the test claim are included in the attached TCRS Readiness Test - Failed Claims Report.

During the on-site readiness test, errors identified by the readiness team were provided to (contractor name) staff for comment. The readiness team reviewed and considered (contractor name) position and determined the “fail” score should remain on these 7 test claims.

The following chart is a summary listing of each error category and the associated number of claims in error:

ERROR CATEGORY NUMBER OF CLAIMS IN ERROR

Benefit Determination Errors 2 Copay/Cost share Errors 2 Non-Covered Charges 1 Pricing Error 2

During the claims evaluation, the readiness team found several incorrect or questionable comments, and miss-spelled words on Explanation of Benefit (EOB) forms. For example, a primary health insurance amount specified as $622.50, while the correct amount was $822.50; a denial reason “non-covered diagnosis”, which should have stated “non-covered procedure”; EOB’s mailed to a sponsor at a minor beneficiary’s address, rather than to the sponsor’s address; miss-spelling of the word “questions” (questions); and it seemed inappropriate to state “Did you know your benefit covers important health and wellness screening services at no cost to you?” on a claim which had cost-shares applied for preventive services, however these error were not addressed by the auditors. As a result, it is recommended that instruction be given to ensure that when reviewing claims EOB messages be reviewed and addressed appropriately.

B. INITIAL REPORT SUMMARY

A low volume of errors/issues were identified during the readiness test. As a result, the overall claims review performance was acceptable and no major issues were identified that would preclude (contractor name) from beginning compliance reviews on (start work date). (Contractor name) has demonstrated the ability to correctly review TRICARE claims, and displayed a firm commitment to successful transition of the TCRS contract. There were no significant trends or major issues identified during the readiness test; therefore, the overall claims review performance is acceptable.

Attachment:

Failed Claims Report

TCRS HT9402-17-R-0002, Section J, Attachment J-3 Page 4 of 4

TCRS READINESS TEST

FAILED CLAIMS REPORT

Test Scenario # : 026 (1) Error Category: Benefit Determination Readiness Team Comments: Charge for CPT 45300, as a preventive procedure, should have been denied, as the patient is outside the allowable age range. Also, CPT 80061 was correctly allowed, but a cost-share should have been applied.

Contractor Comments:

Test Scenario # : 038 (2) Error Category: Benefit Determination Readiness Team Comments: Charges for CPT 82270 and CPT 81000 should have been denied as not medically necessary.

Contractor Comments:

Test Scenario # : 174 (3) Error Category: Cost-Share Error Readiness Team Comments: Charges submitted are for services rendered with a medically necessary diagnosis, and should not have preventive cost-shares applied.

Contractor Comments:

Test Scenario # : 195 (4) Error Category: Cost-Share Error Readiness Team Comments: Charges submitted are for services rendered with a medically necessary diagnosis, and should not have preventive cost-shares applied.

Contractor Comments: