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09/26/2011

Medical Review Progressive Corrective Action (PCA) Process

Medical Review Progressive Corrective Action (PCA) Process

PCA is used to identify potential problem areas and implement the processes performed by Medical Review. This is a comprehensive term that includes the following:

  1. Data analysis
  2. Medical review of claims
  3. Education of providers on the requirements for payment under the Medicare program

Data Analysis

Data analysis is the first step in the PCA process. It includes reviewing claim submissions locally, regionally and nationally for atypical patterns/trends that may indicate a potential problem. Data analysis may be performed based on general surveillance or referrals for specific complaints. These referrals may be initiated from provider or beneficiary sources, fraud alerts, Centers for Medicare & Medicaid Services (CMS) reports, other contractors and /or other government and non-governmental agencies.

Medical Review of Claims

The PCA process involves performing medical review of services billed to Medicare. To determine whether medical review should be performed, several things are taken into consideration, including:

  • The number of claims identified as potentially billed in error
  • The dollars at risk (for example the amount billed and/or the amount paid)
  • The likelihood of an error recurring for an extended period of time

Once the determination is made that medical review is necessary, a probe review is performed to validate that a problem exists. There are two types of probe reviews: service specific and provider specific.

Service-specific probe review usually includes a 100 claim sample based on a specific service (e.g., procedure code, diagnosis, HCPCS, etc.). The claims are selected randomly from providers billing the service in question. The Medical Review department will publish an article in the CGS website notifying providers that a service-specific review is being initiated and an article with the results of the review.

Provider-specific probe review usually includes 20 to 40 claim samples based on claims from the selected provider. The sample of claims selected will be based on the nature of the review (e.g., specific service or various services billed by the selected provider). CGS will notify the provider in writing at the beginning of the review and periodically until the conclusion of the review process.

Once a claim has been selected for review, documentation is requested from the provider billing the service. The request is referred to as an Additional Documentation Request (ADR) letter. Copies of the requested medical records must be submitted within 30 days of the date on the ADR. Failure to submit the requested documentation will result in a denial of all charges on the claim. Once the appropriate number of claims have been reviewed and processed, a charge denial rate (CDR) is calculated. The CDR is determined by dividing the total charges for the claims reviewed and processed into the total denied charges for the claims reviewed and processed. The results are multiplied by 100 and reported as a percentage. This calculation is used to determine the following:

  • The percentage of charges that have been billed in error
  • The extent this error is occurring
  • Guidance to direct additional activities that may be initiated as a result of the review findings

Based on the results of the review, several actions may occur such as:

  • No further action necessary
  • Provider notification and feedback (i.e., individual letters with the results of provider-specific reviews)
  • Additional medical review
  • Referrals to additional governmental agencies
  • Referrals to Provider Outreach and Education

PCA Decision Criteria

Medical Review uses the Progressive Corrective Action Decision Criteria included below. This quick and easy tool assists providers in understanding the PCA process:

Medical Review uses the Progressive Corrective Action Decision Criteria in this decision tree. This quick and easy tool assists providers in understanding the PCA process.

Why Are ADRs So Important?

The Medicare Medical Review department frequently receives medical records without a copy of the request letter or a cover letter with clear identifying information attached to the records.

Why should I attach a copy of the ADR to the medical records?

  • The ADR contains the address of the Medical Review department to which the medical records should be routed. When medical records do not clearly identify the specific person or department to which they should be sent, they may be misrouted to other departments. This can result in a denial because the medical records were not received timely. A copy of the ADR is also needed to identify the specific claim for which the medical records were requested.
  • Medical records without a copy of the ADR attached require additional research and may delay the processing of claims

To Make Sure Your Address is Accurate

Contact the appropriate toll-free Provider Contact Center (PCC), at (866) 590-6703 to verify that your mailing address is correct in our mailing address system. Mail from CGS will not be forwarded if there has been an address change.

Request Response Reminders

  • Separate each request response and attach a copy of the request letter to each individual set of medical records
  • If responding to multiple requests on the same beneficiary for various dates of service, respond to each request letter separately
  • Use one staple in the upper left-hand corner to attach the request letter to the submitted documentation.
  • Do not use paper clips as they can become dislodged in shipping
  • Do not punch holes in the records as this may obscure valuable information
  • Return the records to the address noted on the request letter. Be sure to include the mail code in the address. This assures that your responses are promptly routed to the appropriate destination.
  • Do not include any correspondence other than request responses to the Medical Review department in your envelope. If you have correspondence directed to other departments, please mail them in a separate envelope.

Provider Outreach and Education (POE)

Education regarding the issues identified via the medical review process is an integral part of the PCA process.

Educational opportunities and activities may include:

  • Educational articles posted on the CGS website
  • On-site visits
  • Educational conference calls
  • Information included in in-person workshops, Webinars and Ask-the-Contractor Teleconferences (ACTs)

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