Discovery Sample. The IRO shall randomly select and review a sample of 50 Paid Claims (Discovery Sample). The Paid Claims shall be reviewed based on the supporting documentation available at the Provider’s office or under Provider’s control and applicable billing and coding regulations and guidance to determine whether the claim was correctly coded, submitted, and reimbursed. If the Error Rate (as defined above) for the Discovery Sample is less than 5%, no additional sampling is required, nor is the Systems Review required. (Note: The guidelines listed above do not imply that this is an acceptable error rate. Accordingly, the Provider should, as appropriate, further analyze any errors identified in the Discovery Sample. The Provider recognizes that OIG or other HHS component, in its discretion and as authorized by statute, regulation, or other appropriate authority may also analyze or review Paid Claims included, or errors identified, in the Discovery Sample or any other segment of the universe.)
Discovery Sample. The IRO shall select and review a Discovery Sample of Medicare beneficiaries as described below in Sections 3 and 4. The medical records for the Medicare beneficiaries selected shall be reviewed based on the supporting documentation available at Good Shepherd’s offices or under Good Shepherd’s control and applicable billing and coding regulations and guidance to determine whether the beneficiary was eligible for the hospice benefit and whether all claims for hospice services furnished to the beneficiary were correctly coded, submitted, and reimbursed.
Discovery Sample. The IRO shall randomly select and review a sample of 100 Paid Claims (Discovery Sample). The Paid Claims shall be reviewed based on: (i) the supporting documentation available at Rehab’s office or under Rehab’s control; (ii) appropriate contacts by the IRO with ordering physicians and Rehab customers and/or caregivers of Rehab customers; and (iii) applicable billing and coding regulations and guidance to determine whether the claim was correctly coded, submitted, and reimbursed. Among the issues to be reviewed are: (i) whether the power wheelchairs and accessories were correctly coded, submitted, billed to Federal health care programs appropriately; (ii) whether Rehab maintained in its records documentation of all supporting documentation described in 42 C.F.R. § 410.38(c); and (iii) whether Rehab’s documentation mirrors the documentation the ordering physician’s documentation. At least 25 claims in the Discovery Sample shall include a review of whether Rehab’s documentation mirrors the documentation of the ordering physician. If the Error Rate (as defined above) for the Discovery Sample is less than 5%, no additional sampling is required, nor is the Systems Review required. (Note: The guidelines listed above do not imply that this is an acceptable error rate. Accordingly, Rehab should, as appropriate, further analyze any errors identified in the Discovery Sample. Rehab recognizes that OIG or other HHS component, in its discretion and as authorized by statute, regulation, or other appropriate authority may also analyze or review Paid Claims included, or errors identified, in the Discovery Sample or any other segment of the universe.)
Discovery Sample. The IRO shall randomly select and review a sample of 50 Paid Claims (Discovery Sample). The Paid Claims shall be reviewed based on the supporting documentation available at RMC’s office or under RMC’s control and applicable billing and coding regulations and guidance to determine whether the claim was correctly coded, submitted, and reimbursed. Rural/Metro Corporation Corporate Integrity Agreement Appendix B If the Error Rate (as defined above) for the Discovery Sample is less than 5%, no additional sampling is required, nor is the Systems Review required. (Note: The guidelines listed above do not imply that this is an acceptable error rate. Accordingly, RMC should, as appropriate, further analyze any errors identified in the Discovery Sample. RMC recognizes that OIG or other HHS component, in its discretion and as authorized by statute, regulation, or other appropriate authority may also analyze or review Paid Claims included, or errors identified, in the Discovery Sample or any other segment of the universe.)
Discovery Sample. The IRO shall randomly select and review a sample of 100 Paid Claims (each constituting a “Discovery Sample”) from the Population at each Covered Facility selected for review. The Paid Claims shall be reviewed based on the supporting documentation available at Dignity Health’s office or under Dignity Health’s control and applicable billing and coding regulations and guidance to determine whether the claim was correctly coded, submitted, and reimbursed. If the Error Rate (as defined above) for the Discovery Sample for any Covered Facility is less than 5%, no additional sampling is required, nor is the Systems Review required. (Note: The guidelines listed above do not imply that this is an acceptable error rate. Accordingly, Dignity Health shall, as appropriate, further analyze any errors identified in the Discovery Sample. Dignity Health recognizes that OIG or other HHS component, in its discretion and as authorized by statute, regulation, or other appropriate authority may also analyze or review Paid Claims included, or errors identified, in the Discovery Sample or any other segment of the universe.)
Discovery Sample. The IRO shall randomly select and review a sample of 50 Paid Claims (Discovery Sample). The Paid Claims shall be reviewed based on the supporting documentation available at the CareAll Entities’ office(s) or under the CareAll Entities’ control and applicable billing and coding regulations and guidance to determine whether the claim was correctly coded, submitted, and reimbursed. If the Error Rate (as defined above) for the Discovery Sample is less than 5%, no additional sampling is required, nor is the Systems Review required. (Note: The guidelines listed above do not imply that this is an acceptable error rate. Accordingly, the CareAll Entities should, as appropriate, further analyze any errors identified in the Discovery Sample. The CareAll Entities recognize that OIG or other HHS component, in its discretion and as authorized by statute, regulation, or other appropriate authority may also analyze or review Paid Claims included, or errors identified, in the Discovery Sample or any other segment of the universe.)
Discovery Sample. For each home health facility selected, the IRO shall randomly select and review a sample of 30 Paid Claims (Discovery Sample), resulting in a separate Discovery Sample for each home health facility. The Paid Claims shall be reviewed based on the supporting documentation available at each home health facility or under LHC’s control to determine whether the medical record documentation supports homebound status and medical necessity of the home health services furnished. If the Error Rate (as defined above) for the Discovery Sample for any home health facility is less than 5%, no additional sampling is required, nor is the Systems Review required. (Note: The guidelines listed above do not imply that this is an acceptable error rate. Accordingly, LHC should, as appropriate, further analyze any errors identified in the Discovery Sample. LHC recognizes that OIG or other HHS component, in its discretion and as authorized by statute, regulation, or other appropriate authority may also analyze or review Paid Claims included, or errors identified, in the Discovery Sample or any other segment of the universe.) If the Error Rate for the Discovery Sample for any home health facility is 5% or greater, the IRO shall perform a Full Sample and a Systems Review for the applicable home health facility, as described below.
Discovery Sample. The Billing IRO shall randomly select and review a sample of 200 Paid Claims (Discovery Sample) each
Discovery Sample. The IRO shall randomly select and review a sample of 10 Beneficiary Paid Claims from each of the Clinics in the Sampling Frame. All the Paid Claims shall be reviewed based on the supporting documentation available at Gambro’s office or under Gambro’s control and applicable billing and coding regulations and guidance to determine whether the claim was correctly coded, submitted, and reimbursed.
i. If the Error Rate (as defined in Appendix D) for the Discovery Sample is less than 5%, no additional sampling is required, nor is the Systems Review required. (Note: The guidelines listed above do not imply that this is an acceptable error rate. Accordingly, Gambro should, as appropriate, further analyze any errors identified in the Discovery Sample. Gambro recognizes that OIG or other HHS component, in its discretion and as authorized by statute, regulation, or other appropriate authority may also analyze or review Paid Claims included, or errors identified, in the Discovery Sample or any other segment of the universe.)
ii. If the Discovery Sample indicates that the Error Rate is 5% or greater, the IRO shall perform a Full Sample and a Systems Review, as described below.
Discovery Sample. The IRO shall randomly select and review a sample of 100 Paid Claims (Discovery Sample). The Paid Claims shall be reviewed based on the supporting documentation available at CareMed’s office or under CareMed’s control, (including but not limited to, an electronic or hard copy of the prescription, proof of delivery of the prescription, and any documentation relating to prior authorizations required by the payor for the prescription), applicable billing regulations and guidance, and Part D plan payment provisions to determine whether the claim was correctly submitted and reimbursed. For each Paid Claim reviewed, the IRO should verify that CareMed maintained documentation of (1) the prescription or order for the drug, item, or supply dispensed; (2) the delivery of the drug, item, or supply; and (3) any required preauthorization. If the Error Rate (as defined above) for the Discovery Sample is less than 5%, no additional sampling is required, nor is the Systems Review required. (Note: The guidelines listed above do not imply that this is an acceptable error rate. Accordingly, CareMed should, as appropriate, further analyze any errors identified in the Discovery Sample. CareMed recognizes that OIG or other HHS component, in its discretion and as authorized by statute, regulation, or other appropriate authority may also analyze or review Paid Claims included, or errors identified, in the Discovery Sample or any other segment of the universe.)
