DRG Validation Audit Policy

VIEW HERE

Payment Policies and Audit Program

Payment policies are designed to assist you when submitting claims to Tufts Health Plan. They are consistently updated to promote accurate coding and policy clarification. Payment policies for each of Tufts Health Plan's divisions are located in the Payment Policy section of the Provider Resource Center.

Payment policies by division:

In addition to the specific information contained within each payment policy, providers must adhere to the policy information outlined in the Professional Services and Facilities Payment Policy.
 

Tufts Health Plan's Provider Audit Program

The goal of Tufts Health Plan's Provider Audit Program is to proactively analyze claims data and confirm that claim submissions accurately represent the services provided to members, and to ensure that billing is conducted in accordance with Current Procedural Terminology (CPT) coding guidelines and other applicable standards, rules, laws, regulations, contract provisions, policies and procedures.

As part of an ongoing program to provide outstanding customer service and cost-effective medical care, and as a supplement to other Tufts Health Plan initiatives, such as the Utilization Management Program, the objective of the Provider Audit Program is to ensure that Tufts Health Plan fulfills its responsibility to its risk-sharing partners and/or enrollees and/or Tufts Health Plan sponsors by identifying and recovering inaccurate payments that are a result of inadvertent or intentional provider actions or misrepresentations.

The areas reviewed by the Provider Audit Program include, but are not limited to, the following:

  • Billing for services that were not provided
  • Intentional misrepresentation
  • Billing services at a higher level than which was rendered
  • Failure to comply with the contract/health services agreement, Tufts Health Plan policies and procedures, and/or other relevant guidelines, regulations or laws
  • Inadequate and/or cloned documentation to support the services billed
  • The deliberate performance of unwarranted or medically unnecessary services for the purpose of financial gain

In conjunction with the provisions set forth in the contract/health services agreement with Tufts Health Plan, providers shall:

  • Provide or arrange for health services for members in an economic and efficient manner consistent with professional standards of medical care generally accepted in the medical community at the time
  • Provide or authorize for members only those services which are medically necessary
  • Maintain complete and up-to-date medical records
  • Participate in, and cooperate with, Tufts Health Plan's compliance-related activities and initiatives
  • Bill in accordance with current AMA CPT coding guidelines
  • Comply with all Tufts Health Plan payment policies, including, but not limited to, policies contained in the Claims Manual

In conjunction with the preceding provisions, Tufts Health Plan's Provider Audit Program may:

  • Audit providers
  • Recover funds from providers who engage in improper and/or inappropriate billing practices. Although audits are usually based on claim submissions for up to a four-year period, audits and subsequent recoupment may extend back to the date on which the provider originally became contracted with Tufts Health Plan
  • Impose penalties and/or surcharges and/or interest charges in the settlement of audits
  • Suspend future claim payments once improper billing practices are suspected
  • Close the provider's panel or terminate the provider, in addition to recovering overpayments if the provider intentionally engages in improper billing practices
  • Access medical records of past and present Tufts Health Plan members.

Note: Providers shall grant Tufts Health Plan access to review and copy member medical records within a reasonable period of time following such request. For purposes of this document, "reasonable" shall be defined as a maximum of two weeks from Tufts Health Plan's initial request for access, unless a different time frame is mutually agreed upon by Tufts Health Plan and the provider. Copies may be taken off-site by Tufts Health Plan for additional review during the course of the audit.

In the event that the preceding provisions are inconsistent with any of the terms prescribed by an established contract/health services agreement, the contract/health services agreement shall prevail.

The provisions set forth in the foregoing description of the Provider Audit Program apply to all plans, programs, contractual arrangements and products administered by Tufts Associated Health Plans, Inc. and its affiliates within and across all states and municipalities in which Tufts Health Plan is licensed.

Tufts Health Plan forms are in PDF and require Adobe Reader for viewing and printing. Visit Adobe's website to download Adobe Reader.

plans card