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Medical review is the collection of information and clinical review of medical records by physician advisors (for providers reviewing cases before submissions) or a peer review team (for payers) to ensure that payment is made only for services that meet coverage, coding, and medical necessity requirements. Much of the general commercial medical review policies and processes are influenced by CMS regulations and policies, but individual payers and providers medical review programs share many of the same goals and objectives.

Goal of the Medical Review Program

The goal of the review program is to reduce payment error by identifying and addressing concerning coverage, utilization, and coding. To achieve the goal of any medical review program:

  • Proactively identify and address issues concerning coverage, utilization, and coding through data analysis and evaluation of other information (e.g. complaints)
  • Take action to prevent and/or address the identified error

Progressive Corrective Action (PCA)

PCA is an operational principle upon which medical review activities can be based.  PCA is used to identify potential problem areas and implement the processes performed by Review Teams. This is a comprehensive term includes the following:

  1. Data analysis
  2. Review of claims
  3. Education on the requirements for payment

PCA involves data analysis, error detection, validation of errors, provider education, determination of review type, sampling claims, and payment recovery. It serves as an approach to performing medical review and assists contractors in deciding how to deploy review resources and tools appropriately.

The physician advisors (providers) or a peer review team (payers) may use any relevant information they deem necessary to make a pre-payment or post-payment claim review determination. This includes reviewing any documentation submitted with the case, as well as, additional documentation necessary and in accordance with policies.

Review team goals include:

  • Conduct reviews based on data analysis, which is an essential first step in determining whether patterns or claims submission and payment indicate potential problems.
  • Validate potential problems and review activities should be targeted at identified problems.
  • Only subject reviews to the amount of review necessary to address the nature and extent of the identified problems.
  • When requesting additional documentation for review purposes, the requested documentation is to be submitted within 30 days of the request. If the necessary documentation to make a review determination is not received within 45 days of the request, the  determination based is based on the available documentation.
  • Consider the error rate in deciding how to address a billing problem, give feedback and education as an essential part of solving problems.
  • Track and consider the results of appeals. When a large number of claims denials are overturned on appeal, Taking steps to understand why this is, and to discuss appropriate changes in policies, procedures, outreach, or review strategies.

General Oversight

One distinct roles of the medical review personnel, whether for payer or provider, are to provide oversight such as:

  • Provide broad direction on medical review policy
  • Suggest annual review strategies
  • Facilitate implementation of recently enacted legislation
  • Facilitate compliance with current regulations
  • Ensure performance of operating instructions
  • Conduct continuous monitoring and evaluation of performance
  • Provide ongoing feedback and consultation review issues.

Medical review allows for more efficient patient outcomes and revenue cycles and let healthcare professionals focus on care for individual patients improving everyone’s quality of life.