Medical Review
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What Is Medical Review?
One of the top priorities of the Centers for Medicare & Medicaid Services (CMS) is addressing improper payments in the Medicare fee-for-service program. CMS contracts with three types of contractors to achieve the goal of reducing improper payments. These contractors are:
- Comprehensive Error Rate Testing (CERT) contractors;
- Medicare Administrative Contractors (MACs); and
- Recovery Audit Contractors (RACs).
CMS also strives to protect the program from potential fraud by contracting with Zone Program Integrity Contractors (ZPICs) to identify and stop potential fraud.
CGS is the Durable Medical Equipment Medicare Administrative Contractor (DME MAC) for Jurisdiction C. CGS uses error rates produced by the CERT program and vulnerabilities identified through data analysis and medical review of claims to determine where to target their improper payment prevention efforts.
One of the CGS departments involved with preventing the initial payment of claims that do not comply with Medicare's coverage, coding, payment and billing policies is Medicare Review. The CGS Medical Review department consists of a Medical Director, registered nurses and other clinicians, and specially trained support staff. To achieve the goals of CMS's MR program, CGS Medical Review:
- Identifies supplier noncompliance with coverage, coding, billing, and payment policies through analysis of data and evaluation of other information;
- Takes action to prevent and/or address the identified improper payment; and
- Places emphasis on reducing the paid claims error rate by notifying suppliers of review findings and making appropriate referrals to supplier outreach and education (POE), and other Medicare contractors.
Prepayment and postpayment claim review targeted to those services with the highest improper payments is one strategy that CGS Medical Review utilizes to prevent identified program vulnerabilities. However, Medical Review is not the only CGS department or only Medicare contractor that may request supplier records either for a prepayment or postpayment claim review. Therefore it is essential that suppliers read any correspondence related to additional documentation requests thoroughly and carefully follow the instructions for submitting the requested information. The table below lists the contractors and the types of claims they review in Jurisdiction C:
| Contractor Name | Pre-payment | Post-payment |
|---|---|---|
| CGS – DME MAC Claims | x | |
| CGS – DME MAC Medical Review | x | x |
| CGS – DME MAC Appeals (Redeterminations) | x | |
| CERT Documentation Contractor | x | |
| Safeguard
Services, LLC – Zone 7 Program Integrity Contractor (ZPIC) Florida, Puerto Rico, and Virgin Islands |
x | x |
| Health Integrity, LLC -
Zone 4 Program Integrity Contractor (ZPIC) Colorado, New Mexico, Oklahoma & Texas |
x | x |
| AdvanceMed – Zone 5
Program Integrity Contractor (ZPIC) Arkansas, Alabama, Georgia, Louisiana, Mississippi, North Carolina, South Carolina, Tennessee, West Virginia & Virginia |
x | x |
| Connolly Healthcare – Recovery Audit Contractor (RAC) | x |
Medical review activities performed at CGS also include processing Advance Determination of Medicare Coverage (ADMC) and Power Mobility Prior Authorization Demonstration Project requests.
CMS has prepared a brochure, Medicare Claim Review Programs: MR, NCCI Edits, MUEs, CERT and Recovery Audit Program, for anyone who would like additional information about Medicare clam review programs including MAC medical review activities and responsibilities.
