Overview of Medical Review
Medicare Program Integrity Manual (CMS Pub. 100-08), Ch. 3
The Medical Review (MR) Program is designed to promote a structured approach in the interpretation and implementation of Medicare policies. CMS makes it a priority to automate this process; however, it may require the evaluation of medical records to determine the medical necessity of Medicare claims.
The following summarizes the different activities performed by the Medical Review Department.
- Prepayment Review occurs when edits in the Fiscal Intermediary Standard System (FISS) suspend a claim for medical review before the claim is paid. Prepayment edits may include:
- Targeted Probe and Educate (TPE) – Based on data analysis of claims to identify areas with the greatest risk of inappropriate program payment.
- Providers that have claims selected for prepayment review will receive a Medical Review Additional Development Request (ADR) notice via the FISS.
- Postpayment Review is a comprehensive review of individual beneficiary medical records, conducted either onsite at your facility, or done in the Medicare contractor's Medical Review Department. CGS may perform a postpayment review of claims, meaning that medical documentation is requested for claims that have already been processed and paid. Postpayment review can be done in cases where a high error rate and/or potential overutilization has been identified through data analysis. Postpayment review can be done at the provider's location, or in CGS's Medical Review Department. Upon review of the documentation, CGS Medical Review clinicians will make a determination that either affirms the original payment or denies the payment (in part or in full). If any part of the claim is denied, an overpayment is assessed, and funds are recouped from the provider. Refer to the Medical Review Activity Log Web page for a list of home health and hospice review topics.
- 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.
Updated: 08.25.20