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TPE ProcessPostpayment Review

To protect the Medicare Trust Fund against inappropriate payments, Medicare Administrative Contractors (MACs) are resuming fee-for-service medical review activities. Beginning August 17, the MACs resumed with postpayment reviews of items/services provided before March 1, 2020. The Targeted Probe and Educate program (intensive education to assess provider compliance through up to three rounds of review) will restart later. The MACs will continue to offer detailed review decisions and education as appropriate.

CGS may perform a post payment review of claims, meaning that medical documentation is requested for claims that have already been processed and paid. Post payment review can be done in cases where a high error rate and/or potential overutilization has been identified through data analysis. Post payment 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 to either allow the original payment or deny 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 Part A Medical Review Activity Log for a list of Part A review topics.


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