In April and May of 2001 the MOM (MACSIS Management and Operations) committee was examining MACSIS Production claims and noticed the existence of "outliers," i.e., claims with large values in Allowed Amount and/or Units of Service. An inquiry (to the submitting) Board about samples of such claims identified these as "billing errors" that should have not been submitted or should have been denied. These claims were however routinely being processed into the system, finalized with Diamond 725, and even at times, extracted as Medicaid submissions to ODJFS (Ohio Department of Jobs and Family Services).
It was proposed we build "Notify" Reports. We will examine the MACSIS database each weekend for "person claims" submitted to the system (i.e., posted) which are as yet not-finalized and fall into this "outlier" class -- such "outliers" (today) are defined as "greater than 5 units for sixty minute services", "greater than 20 units for fifteen minute services" or "allowed amount greater than $400." A list of such outlier claims will be constructed and provided to each (submitting) Board. The detailed criteria for inclusion in the "outlier" list are provided below.
There are four reports created for each board (if there are claims meeting the criteria) and four reports for each provider (if there are claims meeting the criteria). These files have been encrypted and the naming conventions are listed below. These reports are placed in the "extracts" subdirectory of the Board's FTP area on the mhhub.odn.state.oh.us server. Our expectation is that these report files will be placed in the /county directories on Sunday afternoon or evening -- our plan is to have them available to Boards by at least Monday morning before 8 AM.
The naming convention for these reports are (the encrypted file name is in bold):
This is a "notify" process only – the claims are unchanged by us in Diamond. We are asking that Board staff review and inquire of these "outliers" before they become finalized within MACSIS. Our expectation is that the Provider be queried, that questionable claims be reviewed and placed on hold or denied as appropriate. These claims should not be allowed to be finalized as valid submissions until the Board has reviewed the claims with the Provider and verified that a billing error has not occurred.
For detailed documentation of the program, refer to “HIPAA Database Notify Program: Outliers and Holds Reports”.