TMPPM 2008 > Texas Medicaid Services > Hospital (Medical/Surgical Acute Care Facility) > Outpatient

25.3.4.1 Responsibilities

TMHP is responsible for a comprehensive integrated review process to identify misuse and inappropriate billing patterns by outpatient hospitals and HASCs. All providers are subject to TMHP's UR monitoring. Providers are selected for review based on a comparison of their individual resource utilization with a peer group of similar specialty and geographic locality. The main goal of the required utilization control is to identify those providers whose practice patterns are aberrant from their peers and provide the necessary educational actions to help the provider achieve Texas Medicaid Program compliance. An analysis of UR data is completed by a registered nurse analyst for review by the medical director and staff. If the analyst substantiates that a provider's practice and billing patterns are inconsistent with the federal requirements and the Texas Medicaid Program's scope of benefits, a TMHP representative contacts the provider. The purpose of the contact is to discuss appropriate billing guidelines and to assist the provider in resolving the inappropriate billing patterns identified in the review.

TMHP uses the following criteria when reviewing all hospital outpatient medical records. Services must be:

•Medically necessary.

•Ordered by a physician, signed, and dated. Signature stamps are valid if initialed and dated by the physician.

•Billed in the quantities ordered and documented as provided.

•Program benefits.

•Specifically identified on the charge tickets or itemized statement submitted with the claim or by the HCPCS procedure code on the claim.

•Billed to the Texas Medicaid Program only after other medical insurance resources have been exhausted.

Refer to: "Medicaid Identification (Form H3087)" .

•Indicated by the documentation in the medical record.

The determination of TMHP's UR process may result in the following:

•Educational letters/visits.

•Mail-in of medical records for review.

•On-site medical record review (outpatient, ASC/HASC, or inpatient records not reviewed).

•Referral of questionable claims to HHSC or HHSC OIG.

•Recoupment.

•Prepayment review.

The intent of these actions is to ensure the most effective and appropriate use of available services and facilities and provide appropriate, cost-effective care to clients with Medicaid coverage.