Auditing Begins for Medicare Plus Blue’s Reimbursed Diagnosis-Related Group Claims

Medical Billing

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HMS will begin auditing Medicare Plus Blue PPO’s reimbursed diagnosis-related group claims for clinical and coding validation, starting Sept. 1, 2019. HMS is an independent company working for Blue Cross Blue Shield of Michigan.

The audits will review medical records to ensure claims were billed in accordance with coding guidelines, and diagnoses were supported by documentation in the medical record.

Be ready to share medical charts for review. After an audit, HMS will send the findings and information on how you can ask for an appeal, if necessary.

The purpose of the clinical audit of the diagnosis-related group, or DRG, is to:

  • Confirm compliance with national coding guidelines.
  • Ensure documentation supports diagnoses and procedures reported.
  • Detect, prevent and correct waste and abuse.
  • Facilitate accurate claim payments.

HMS will be holding webinars for providers with information on the overall DRG clinical validation process and helpful tips. Schedules will be provided in a future web-DENIS message.

DRG clinical validation audits take a three-phase approach. See the scope of each phase and the data period for each phase in the chart below.

Phase 1:
Sept. 1 to Nov. 30, 2019
Providers receive audit finding letters, but no recoupment will come from Blue Cross. Audits are educational only. Data period:
Dates of service are Jan. 1 to April 30, 2019.
Phase 2:
Dec. 1, 2019, to Feb. 28, 2020
Recoupment begins on claims with DRG findings. Providers won’t be charged for appeals on claims. Data period:
Dates of service are May 1 to Nov. 30, 2019.
Phase 3:
March 1, 2020
DRG clinical validation audits are fully implemented. Providers will follow the existing audit and appeal process. Recoupment occurs. Claims selected from claims not previously selected within the proper audit review period.


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