Medicare's Medical Review Program
Medical Review (MR) is an important part of the Medicare Integrity program that requires Contractors to verify inappropriate billing and to develop interventions to correct the problem. MR is defined as a review of claims to determine whether services provided are medically reasonable and necessary, as well as to follow-up on the effectiveness of previous corrective actions. The goal is to reduce the payment error rate by identifying and addressing billing errors concerning coverage and coding made by providers. MR initiatives are designed to ensure that Medicare claims are paid correctly while helping to maintain the integrity of the Medicare program. Providers benefit from this program by:
- Reducing the overall claims payment error rate
- Reduction in filing errors
- Increase in timely payments, and
- Increased educational opportunities
The Medical Review Process
Providers may be selected for MR when a typical billing patterns are identified, or when a particular kind of problem is identified (i.e. errors in billing a specific type of service). MR functions may be performed for all claims appropriately submitted to Medicare with the exception of acute care inpatient hospital prospective payment system (PPS), diagnosis related group claims (DRG), or long term care hospital claims (LTCH), Quality Improvement Organizations (QIO) perform these reviews.
Through data analysis and evaluation of other information (i.e., complaints) suspected billing problems are identified, to ensure activities are targeted at identified problem areas and that the corrective actions are appropriate for the severity of the problem MR uses Progressive Corrective Action (PCA). Prior to assigning significant resources to examine claims identified as potential problems, MR validates claim errors through the use of probe reviews.
During a probe review (20-40 claims per provider) or a widespread probe reviews (100 claims from multiple providers) providers are notified that the review is being conducted and asked to provide medical documentation for the claims in question, once the review is completed providers are notified of their results. If a probe review verify that an error exists it is classified as minor, moderate, or significant. Corrective actions that may result from MR review, provider education, prepayment (review prior to payment) review, or postpayment (uses Statistically Valid Sampling) review, both pre and post payment review require providers to submit documentation. Once providers have re-established the practice of billing correctly they are removed from review.
Provider feedback and education regarding MR findings is an essential part of all corrective actions.
The Provider's Role
The purpose of the MR process is to make sure claims are paid correctly. You can help meet this goal by:
- Reviewing and reading all publications and LCDs so you are aware of coverage requirements
- Familiarizing office staff and billing vendors with filing rules
- Checking your records against billed claims
- Performing self audits
MR may request documentation to support the services under review. Please keep in mind the following points:
- You must supply documentation
- Documentation should support medical necessity
- Documentation must be legible and signed
- Services must be coded correctly
You have the right to be educated on how to bill correctly and to have questions answered in a timely manner. You have the right to appeal as long as the appeal is filed in accordance with appeal regulations.
