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Process Improvement Plans

When a probe review identifies documentation deficiencies or other nonconformances with Medicare polices, CGS may request that a supplier submit a Process Improvement Plan (PIP). Preparing a PIP guides the supplier through a problem solving process with the goal of identifying root causes of the nonconformances and designing corrective actions that include controls to prevent recurrences.

Before writing a PIP, review the probe findings letter carefully. This letter lists the deficiencies identified by the clinician who reviewed the sample claims and references the citations upon which the decisions were based upon. This information will aid you in completing the first step in the corrective action process which is to define the problem(s)/issue(s). Answering the following questions also help define the problems:

  • What is happening?
  • What should be happening?
  • Why is this problem occurring?
  • What is the effect?
  • How can this be fixed?

The next corrective action step is to determine the root cause(s) of each problem. It is very important to identify the root cause as opposed to merely addressing the immediately obvious symptoms. Unless the corrective action eliminates the root cause, the problem is likely to recur.

Simply stated, the root cause can be analyzed by asking why the problem occurred and then continuing to ask why until you reach the fundamental process element that failed.


Problem – A grease fire spread out of a skillet and destroyed my kitchen.

Why – The fire spread when I poured water on it.

Why – The fire extinguisher I tried to use did not work.

Why – The fire extinguisher was empty.

Why – I did not perform a maintenance check to make sure it was charged.

Only when you are able to determine why the problem occurred will you be able to specify workable corrective measures that will prevent future occurrences of the problems identified in the probe review.

Once the root cause has been identified, it is time to work on solutions. Be sure not to rush this step since there may be more than one effective solution. The solution(s) should lower the risk of the event recurring and also have a low potential for other adverse effects. As you develop a solution, consider the following:

  • Is this a feasible solution for my company? Can it be implemented with the company's resources and schedule?
  • Is the solution going to be effective? Does it have a reasonable probability of solving the problem?
  • Is the cost of the solution within the company's budget and appropriate for the extent of the problem?
  • Have I involved the employees affected by the problem in the creation of the solution?

The fourth step in the corrective action process is to set target dates for implementing the solutions. While these due dates should be realistic and achievable, it is equally important that implementation begin as soon as possible.

A very important aspect of corrective action is the monitoring process. Therefore internal controls must be established to enhance risk management and increase the likelihood that the solutions will not only be implemented but will remain in place. When addressing this step in your PIP, include:

  • The kind of monitoring process;
  • Monitoring criteria; and
  • Frequency of evaluation.

The PIP should also identify the staff person responsible for the implementation and evaluation of each individual step in the process improvement plan as well as the person with overall responsibility for the entire PIP.

Process Improvement Plan Form

CGS has developed an optional PIP form for suppliers to use when completing a process improvement plan. Suppliers may use other formats of their choosing as long as the plan addresses the elements outlined above.

For PIP questions specific to your probe review case, please refer to the probe review findings letter for contact information.

Updated 02.28.18


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