Goal of MAC and SMRC MR Program

1.3.8 - Goal of MAC and SMRC MR Program (Rev. 10365; Issued: 10-02-20; Effective: 08-27-20; Implementation: 08-27-20) The goal of the MAC and SMRC MR program is to reduce payment error by preventing the initial payment of claims that do not comply with Medicare’s with coverage, coding, payment, and billing policies. To achieve the goal of the MR program, MACs: • Identify provider noncompliance with coverage, coding, billing, and payment policies through analysis of data. (e.g., profiling of providers, services, or beneficiary utilization) and evaluation of other information (e.g., complaints, enrollment and/or cost report data). (Chapter 2 describes these activities in further detail.); • Take action to prevent and/or address the identified improper payment; (chapter 3, describes these actions in further detail.); and • Place emphasis on reducing the paid claims error rate by notifying the individual billing entities (i.e., providers, suppliers, or other approved clinician) of review findings identified by the ACs or by the MACs and making appropriate referrals to provider outreach and education (POE), and UPICs. SMRC: • Identify provider noncompliance with coverage, coding, billing, and payment policies through the research and analysis of data related to assigned task. (e.g., profiling of providers, services, or beneficiary utilization) • As directed by CMS, perform medical review • As directed by CMS, perform extrapolation • Notify the individual billing entities (i.e., providers, suppliers, or other approved clinician) of review findings identified and make appropriate recommendations for POE and UPIC referrals