Progressive Corrective Action
Medicare Program Integrity Manual, Pub. 100-08, Chapter 3, Section 3.11
Contractors must analyze provider compliance with Medicare coverage and coding rules and take appropriate corrective action when providers are found to be non-compliant. Progressive Corrective Action (PCA) provides Medicare contractors with further guidance, underlying principles and approaches to be used in deciding how to deploy resources and tools for Medical Review. One of the main objectives of the PCA is to provide Medicare contractors with consistent approaches to imposing corrective actions on providers.
Corrective actions include:
- Provider education and feedback
- Prepay medical review (MR)
- Local Coverage Decisions (LCD) development
- Post-pay review
- Program Safeguard Contractor (PSC) referrals
The principles of PCA include:
- Data driven analysis and review
- Testing of hypothesis with "Probe Reviews"
- Prioritizing and targeting MR activities
- Requesting additional documentation
- Considering provider error rate
- Feedback to providers
- Collection of money when errors are identified
- Appropriate fraud referrals
- Track MR interventions and appeals
- Provider training and resources
Updated: 07.30.12
