Medical Review for Program Integrity Purposes

4.7.4 – Medical Review for Program Integrity Purposes (Rev. 11358; Issued: 04-21-2022; Effective: 05-23-2022; Implementation: 05-23- 2022) Medical Review (MR) for Program Integrity (PI) is one of the parallel strategies of the Medicare Integrity Program (MIP) to encourage the early detection of fraud, waste, and abuse. The primary task of the UPIC is to identify suspected fraud, develop investigations and cases thoroughly and in a timely manner, and take immediate action to ensure that Medicare Trust Fund monies are not inappropriately paid out and that any improper payments are identified. For this reason, it is recommended that MR is integrated early into the development of the investigative process. The focus of PI MR includes, but is not limited to: • Possible falsification or other evidence of alterations of medical record documentation including, but not limited to: obliterated sections; missing pages, inserted pages, white out; and excessive late entries; • Evidence that the service billed for was actually provided and/or provided as billed; or, • Patterns and trends that may indicate potential fraud, waste, and abuse. The statutory authority for the MR program includes the following sections of the Social Security Act (the Act): • Section 1833(e), which states in part "...no payment shall be made to any provider... unless there has been furnished such information as may be necessary in order to determine the amounts due such provider ...;" • Section 1842(a)(2)(B), which requires MACs to "assist in the application of safeguards against unnecessary utilization of services furnished by providers ...; " • Section 1862(a)(1), which states no Medicare payment shall be made for expenses incurred for items or services that "are not reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member;" The remainder of Section 1862(a), which describes all statutory exclusions from coverage; • Section 1893(b)(1) establishes the Medicare Integrity Program, which allows contractors to review activities of providers of services or other individuals and entities furnishing items and services for which payment may be made under this title (including skilled nursing facilities and home health agencies), including medical and utilization review and fraud review (employing similar standards, processes, and technologies used by private health plans, including equipment and software technologies which surpass the capability of the equipment and technologies. . .”) • Sections 1812, 1861, and 1832, which describe the Medicare benefit categories; and • Sections 1874, 1816, and 1842, which provide further authority. The regulatory authority for the MR program rests in: • 42 CFR §421.100 for intermediaries. • 42 CFR §421.200 for carriers. • 42 CFR §421.400 for MACs. Data analysis is an essential first step in determining whether patterns of claims submission and payment indicate potential problems. Such data analysis may include simple identification of aberrancies in billing patterns within a homogeneous group, or much more sophisticated detection of patterns within claims or groups of claims that might suggest improper billing or payment. The UPIC’s ability to make use of available data and apply innovative analytical methodologies is critical to the success of MR for PI purposes. Refer to PIM chapter 2 in its entirety for MR and PI data analysis requirements. The UPIC and the MAC MR units shall have ongoing discussions and close working relationships regarding situations identified that may be signs of potential fraud, waste, or abuse. MACs shall also include the cost report audit unit in the on-going discussions. MAC MR staff shall coordinate and communicate with their associated UPICs to ensure coordination of efforts, to prevent inappropriate duplication of review activities, and to assure contacts made by the MAC are not in conflict with program integrity related activities, as defined by the Joint Operating Agreement (JOA). It is essential that MR is integrated early in the investigative plan of action to facilitate the timeliness of the investigative process. Before deploying significant MR resources to examine claims identified as potentially fraudulent, the UPIC may perform a limited prepayment MR to help identify signs of potential fraud, waste, or abuse. The general recommendation for a provider/supplier specific edit would be to limit the prepayment MR to specific procedure codes, a specific number of claims, or based on a particular subset of beneficiaries identified through the UPIC’s analysis. Another option may be for the UPIC to perform a MR probe to validate the data analysis or allegation by selecting a small representative sample of claims. The general recommendation for a provider/supplier-specific probe sample is 20-40 claims. This sample size should be sufficient to determine the need for additional prepayment or post-payment MR actions. MR resources shall be used efficiently and not cause a delay in the investigative process. In addition, development of an investigation shall continue while the contractor is awaiting the results of the MR. A. Referrals from the Medicare Administrative Contractor or Recovery Audit Contractor to the Unified Program Integrity Contractor If a provider/supplier appears to have knowingly and intentionally furnished services that are not covered, or filed claims for services not furnished as billed, or made any false statement on the claim or supporting documentation to receive payment, the MAC or RAC personnel may discuss potential referral of the matter to the UPIC. If the UPIC agrees that there is potential fraud, waste, and/or abuse, the MAC or RAC personnel shall escalate and refer the matter to the UPIC. Provider/supplier documentation that shows a pattern of repeated misconduct or conduct that is clearly abusive or potentially fraudulent, despite provider/supplier education and direct contact with the provider/supplier to explain identified errors, shall be referred to the UPIC. The focus of MAC MR is to reduce the error rate through MR and provider/supplier notification and feedback. The focus of the RAC is to identify and correct Medicare improper payments through detection and collection of overpayments. The focus of the UPIC is to address situations of potential fraud, waste, and abuse. B. Referrals from the Unified Program Integrity Contractor to the Medical Review Unit and Other Units The UPICs are also responsible for preventing and minimizing the opportunity for fraud. The UPICs shall identify procedures that may make Medicare vulnerable to questionable billing or improper practices and take appropriate action. CMS has implemented recurring edit modules in all claims processing systems to allow UPICs and/or CMS to monitor specific beneficiary and/or provider/supplier numbers and other claims criteria. When appropriate, the UPIC may request the MAC to install a prepayment or auto-denial edit. The MACs shall comply with requests from UPICs and/or CMS to implement those edits. The MACs shall implement parameters for those edits/audits within the timeframe established in the MAC and UPIC JOA, which shall not exceed more than 15 business days. C. Program Integrity/Medical Review Determinations When MAC MR staff is reviewing a medical record for MR purposes, its focus is on making a coverage and/or coding determination. However, when UPIC staff is performing MR for PI purposes, its focus may be different (e.g., looking for possible falsification). The UPIC shall follow all chapters of the PIM as applicable unless otherwise instructed in this chapter and/or in its Umbrella Statement of Work (USOW). Of note, should the UPIC have evidence that services were not performed (i.e., from beneficiary interview(s), provider attestation(s), etc.), the UPIC may deny the service(s) based on that evidence without the need for medical review. Chapter 3 of the PIM outlines the procedures to be followed to make coverage and coding determinations. 1. The UPIC shall maintain current references to support MR determinations. The review staff shall be familiar with the below references and be able to track requirements in the internal review guidelines back to the statute or manual. References include, but are not limited to: • CFRs; • CMS Internet Only Manuals (IOMs); • Local coverage determinations (LCDs); • National coverage determinations (NCDs); and • Internal review guidelines (sometimes defined as desktop procedures). 2. The UPIC shall have specific review parameters and guidelines established for the identified claims. Each claim shall be evaluated using the same review guidelines. The claim and the medical record shall be linked by patient name, HICN, diagnosis, Internal Control Number (ICN), and procedure. The UPIC shall have access to provider/supplier tracking systems from MR. The information on the tracking systems shall be used for comparison to UPIC findings. The UPIC shall also consider that the MR department may have established internal guidelines (see PIM, chapter 3). 3. The UPIC shall evaluate if the provider specialty is reasonable for the procedure(s) being reviewed. As examples, one would not expect to see chiropractors billing for cardiac care, podiatrists for dermatological procedures, and ophthalmologists for foot care. 4. The UPIC shall evaluate and determine if there is evidence in the medical record that the service submitted was actually provided, and if so, if the service was medically reasonable and necessary. The UPIC shall also verify diagnosis and match to age, gender, and procedure. 5. The UPIC shall determine if patterns and/or trends exist in the medical record that may indicate potential fraud, waste, or abuse or demonstrate potential patient harm. Examples include, but are not limited to: • The medical records tend to have obvious or nearly identical documentation. • In reviews that cover a sequence of codes (e.g., evaluation and management codes, therapies, radiology), evidence may exist of a trend to use with greater frequency than would be expected the high-end billing codes representing higher level services. • In a provider/supplier review, a pattern may be identified of billing more hours of care than would normally be expected on a given workday. • The medical records indicate a procedure is being done more frequently than prescribed per suggested CMS guidance or industry standards of care, resulting in potential situations of patient harm. 6. The UPIC shall evaluate the medical record for evidence of alterations including, but not limited to, obliterated sections, missing pages, inserted pages, white out, and excessive late entries. The UPIC shall not consider undated or unsigned entries handwritten in the margin of a document. These entries shall be excluded from consideration when performing medical review. See chapter 3 for recordkeeping principles. 7. The UPIC shall document errors found and communicate these to the provider/supplier in writing when the UPIC’s review does not find evidence of questionable billing or improper practices. A referral may be made to the POE staff at the MAC for additional provider/supplier education and follow up, if appropriate (see PIM, chapter 3). 8. The UPIC shall adjust the service, in part or in whole, depending upon the service under review, when medical records/documentation do not support services billed by the provider/supplier. 9. The UPIC shall thoroughly document the rationale utilized to make the MR decision. D. Quality Assurance Quality assurance activities shall ensure that each element is being performed consistently and accurately throughout the UPIC’s MR for PI program. In addition, the UPIC shall have in place procedures for continuous quality improvement in order to continually improve the effectiveness of their processes. 1. The UPIC shall assess the need for internal training on changes or new instructions (e.g., through minutes, agendas, sign-in sheets) and confirm with staff that they have participated in training as appropriate. The UPIC staff shall be able to request training on specific issues. 2. The UPIC shall evaluate internal mechanisms to determine whether staff members have correctly interpreted the training (training evaluation forms, staff assessments) and demonstrated the ability to implement the instruction (internal quality assessment processes). 3. The UPIC shall have an objective process to assign staff to review projects, ensuring that the correct level of expertise is available. For example, situations dealing with therapy issues may include review by an appropriate therapist or use of a therapist as a consultant to develop internal guidelines. Situations with complicated or questionable medical issues, or where no policy exists, may require a physician consultant (medical director or outside consultant). 4. The UPIC shall develop a system to address how it will monitor and maintain accuracy in decision making (inter-reviewer reliability) as referenced in chapter 3 of the PIM. The UPIC shall establish a Quality Improvement (QI) process that verifies the accuracy of MR decisions made by licensed health care professionals. UPICs shall include inter-rater reliability and/or peer- review assessments in their QI process and shall report these results as directed by CMS. 5. When the UPIC evaluation results identify the need for prepayment edit placement at the MAC, the UPIC shall have a system in place to evaluate the effectiveness of those edits on an ongoing basis as development continues. The MAC may provide the claims data necessary to the UPIC to evaluate edits submitted at the request of the UPIC. The evaluation of edits shall consider the timing and staffing needs for reviews. The UPIC may submit an inquiry to the MAC to verify that a new edit is accomplishing its objective of selecting claims for MR 30 business days after an edit has been implemented or placed into production. The UPIC shall use data analysis of the selected provider’s claims history to verify possible changes in billing patterns. Automated edits shall be evaluated annually. Prepayment edits shall be evaluated on a quarterly basis. They shall be analyzed in conjunction with data analysis to confirm or re-establish priorities. For example, a prepayment edit is implemented to stop all claims with a specific diagnostic/procedure code and the provider stops submitting claims with that code to circumvent the edit. Data analysis shall be used to identify if the provider’s general billing pattern has changed in volume and/or to another/similar code that may need to be considered/evaluated to revise the current edit in question and/or expansion of the current investigation.