Editor’s Note: BHM, like the CMS, believes that the medical review process is critical to reducing Medicare fraud and payment errors. As an organization which provides the highest level of consistent quality independent medical reviews, BHM understands the importance of providing meaningful reporting and data throughout the review process. Click for our new eBook on Peer Review services or HERE to contact us.

The medical reviews process is critical to healthcare ecosystem. The process helps protect against Medicare fraud and the many risks associated with atypical billing patterns and payments. The Social Security Act outlines very specific guidelines for reducing medical review error.  Medicare contractors are used to help review data and medical records. Contractors ensure requirements for Part A and Part are in place and that claims data is reviewed for any errors. Through the collection of data and data analysis, medical reviews ensure that Medicare payments are not only met but also that they follow strict coverage, coding and medical necessity requirements.

Why a Medical Review Program?

Medical review programs are put into place to reduce payment error. By analyzing data, such as billing and coding information, Medical review programs are able to isolate important errors concerning coverage or coding impacting the payment process.

According to CMS in order to achieve this goal, Medicare contractors must:

  • Proactively identify patterns of potential billing errors concerning Medicare coverage and coding made by providers through data analysis and evaluation of other information (e.g. complaints);
  • Review CERT data, RAC vulnerabilities and OIG/GAO reports;
  • Take action to prevent and/or address the identified error;
  •  Publish local medical review policy (called Local Coverage Determination-(LCD)) to provide guidance to the public and medical community about when items and services will be eligible for payment under the Medicare statute; and
  • Publish MLN (Medicare Learning Network) educational articles as they relate to the medical review process.

What is Progressive Corrective Action (PCA)?

The CMS states that PCA is an “operational principle upon which all medical review activities are based.” The PCA process and any relevant data helps Medical Contractors make informed decisions on medical reviews.

PCA includes:

  • data analysis
  • error detection
  • validation of errors
  • provider education
  • determination of review type
  • sampling claims
  • payment recovery

Contractors are used to:

  • Review and approve Medicare Contractors’ annual medical review strategies
  • Facilitate Medicare Contractors’ implementation of recently enacted Medicare legislation
  • Facilitate compliance with current regulations
  • Ensure Medicare Contractors’ performance of CMS operating instructions
  • Conduct continuous monitoring and evaluation of Medicare Contractors’ performance in accord with CMS program instructions as well as contractors’ strategies and goals
  • Provide ongoing feedback and consultation to contractors regarding Medicare program and medical review issues.