Medicare Program Integrity Manual (Pub. 100-08), Ch. 7 § 7.1.2.3
Data Analysis and Information Gathering Plan
7.1.2.3 - Data Analysis and Information Gathering Plan
(Rev. 599, Issued: 06-26-15, Effective: 12-07-15, Implementation: 12-07-15)
The MAC shall target their efforts on those services, items, and providers/suppliers in their
jurisdiction that pose the greatest financial risk to the Medicare Trust Fund and that represent
the best investment of resources to reduce the national improper payment rate (IPR).
The first step in creating or updating an IPRS is to establish a priority-setting process to
assure MR activities and other interventions are focused on areas with the greatest potential
for improper payments. The MACs shall analyze and gather data from a variety of sources
for this purpose. The MACs’ Comprehensive Error Rate Testing (CERT) findings shall
be used as a primary source of data. However, CERT findings are only one indication of
where to focus and shall not be relied upon as the single source of data information. The
MAC shall consult a variety of resources. Examples of other appropriate resources
include, but are not limited to:
• Recovery Auditor-identified problem
• Comparative billing reports (CBRs)
• Office of Inspector General (OIG) or Government Accountability Office (GAO)
reports
• MAC data analysis on a specific benefit, diagnostic/procedure code, or place of
service. This analysis shall include an identification of the specific cause of
improper payments
• Evaluation of utilization or probes
The MAC shall provide detailed information of the data analysis conducted for purposes
of developing the IPRS. The data analysis plan shall list the data resources used in
developing the prioritized problem list. If a prioritized problem is carried over from a
previous IPRS or Strategy Analysis Report (SAR) the MAC shall provide information
regarding the current, updated data analysis conducted to ensure that the prioritization of
the problem is accurate and current. If a former prioritized problem is not carried over
from a previous IPRS or SAR, an explanation and data shall also be provided.