In June, Palmetto GBA embarked on a Centers of Medicare and Medicaid Services’ (CMS) medical review pilot program in the Jurisdiction J A/B MAC. We proposed this initiative to fulfill the requirements of CMS’ Statement of Objectives (SOO) related to “Increased Medical Review Sustained Activities” funding.   

Palmetto GBA is working on a proof of concept to use Optum’s LifeCode^® clinical language intelligence (CLI) platform to scan unstructured medical documentation that is received through our eServices provider portal. Palmetto GBA is utilizing its vast medical review experience to train sophisticated natural language processing (NLP) and machine learning (ML) algorithms to identify and interpret the text. The new process will identify if the documentation meets Medicare requirements to support the service. 

This review will take place as soon as the documents are submitted and delivers real-time results to the provider letting them know if they need to provide additional documentation. This allows providers to correct problematic claims earlier in the process and helps reduce payment time.