F Controls – Medical Review (MR)

50.6 – F Controls – Medical Review (MR) (Rev. 308, Issued: 10-26-18 Effective: 09- 01- 18, Implementation: 11-27-18) F – Control Number Control Objective – Medical Review (MR) F.1 Contractor shall use the Program Integrity Manual (PIM) guidelines, data analysis (prior year and most current) and Medical Review (MR) results including Strategy Analysis Report (SAR), and Comprehensive Error Rate Testing (CERT) results to develop and update the Improper Payment Reduction Strategy (IPRS). The problem-focused outcome-based IPRS report shall address provider specific problems, and service-specific problems only in the rare circumstance it is approved by CMS. The IPRS shall focus its medical review activities toward the goal of reducing the claims improper payment rate. All work performed by the MR unit shall be identified in the IPRS and targeted based on the contractor’s prioritized problem list or as directed by CMS. F.2 Contractor shall budget and perform the MR workloads throughout the year as established in the IPRS. MACs shall report workload volume, and costs associated with MR activities in CMS Analysis, Reporting, and Tracking (ART) systems or as directed by the COR. MACs shall explain any significant fluctuations in workload or costs in the Monthly Status Report and SAR. F.3 Contractor shall perform data analysis continuously to identify potential problems such as aberrant billing practices, potential of over-utilization areas, and changes in patterns of care to target medical review activities to reduce the claims improper payment rate. Data from a variety of sources must be used for data analysis. At a minimum, sources include: contractor internal data; CMS program vulnerability alerts such as Quarterly Vulnerability Technical Direction Letters that require corrective action reporting, FATHOM/PEPPER and other comparative billing reports; results from medical review studies performed by specialty MR or Program Integrity contractors; and other national or regional sources such as Office of Inspector General (OIG) reports, Government Accountability Office (GAO) reports, enrollment data, and fraud alerts. F.4 Contractor shall ensure that effective MR edits are developed and implemented as a result of data analysis findings and policies. The effectiveness of each MR edit shall be analyzed and measured by tracking the denial rate, appeals reversal rate, basis of the appeals reversal, and the dollar return on the cost of operationalizing the edit (savings), and success of edit towards billing behavior correction. MR edits shall be modified, deleted, or deactivated when they are determined to no longer be effective. F – Control Number Control Objective – Medical Review (MR) F.5 Contractor shall utilize the Progressive Corrective Action (PCA) process and Targeted Probe and Educate (TPE) process, in accordance with the Pub. 100-08 and CMS instructions, to drive MR activity (i.e., data analysis, claims review, medical review education). PCA would only apply to MR activity performed before TPE was started by the MAC and/or in a CMS approved MR activity. F.6 Contractor shall be capable of identifying the status of each claim subjected to medical review at any time (and all claims must be processed timely for closure in accordance with Pub. 100-08 instructions). F.7 Control number F.7 reserved. Control not in use as of IOM revision number 278. F.8 The MR unit shall effectively collaborate with Provider Outreach and Education (POE) by referring educational needs that will address existing program vulnerabilities and emerging problems identified during the MR process conducted throughout the fiscal year. F.9 Contractor shall implement and utilize a Provider Tracking System (PTS) to track all informational provider contacts made by medical review and all educational referrals submitted to POE and external organizations. F.10 Contractor shall ensure that there is adequate internal networking and sharing of information, and appropriate collaborative actions are taken as a result, between MR and other business functions such as Appeals, Audits, POE, and inquiries and external organizations such as the Zone Program Integrity Contractors (ZPIC), Unified Program Integrity Contractors (UPIC), Recovery Auditors, and Quality Improvement Organizations (QIOs). F.11 Contractor shall apply quality assurance processes to all elements of the MR Strategy and to all aspects of program management, data analysis, edit effectiveness, problem identification, and claim adjudication. F.12 Contractor shall effectively comply with all of the MR requirements of the Joint Operating Agreement (JOA) with the PSCs/ZPICs and Recovery Auditors, and other entities as directed by CMS. F – Control Number Control Objective – Medical Review (MR) F.13 Contractor shall institute a corrective action reporting process for claims-specific errors and vulnerabilities in accordance with PIM 3.7.5. For each issue, MACs shall report interim actions, final actions, and action dates. End Section 50.6 – F Controls – Medical Review (MR): Back to Table of Contents