Medical Review Program is performed by - Macs, ZPICs/PSCs, and SMRCs
Claim Review contractors identify suspected improper billing through - Error rates produced by the CERT Program, vulnerabilities identified through the Recovery Audit Program, claim data analysis, and evaluation of other info...
CPMA Exam Correctly Solved Rate A+
Medical Review Program is performed by - ✅✅ Macs, ZPICs/PSCs, and SMRCs
Claim Review contractors identify suspected improper billing through - ✅✅ Error
rates produced by the CERT Program, vulnerabilities identified through the Recovery Audit Program, claim data analysis, and evaluation of other information (for example, complaints).
Generally, claim review contractors focus Medical Review (MR) activities on identified - ✅✅ problem areas and Select appropriate action for the severity of the problem.
3 types of corrective actions can result from a Medical Review (MR) - ✅✅ 1. Provider Education/Feedback
2. Prepayment review 3. Postpayment review.
SMRC reviews are selected by - ✅✅ CMS
Both Prepayment and Postpayment reviews may require - ✅✅ Providers to submit
medical records
To help prevent improper payments, the MAC's - ✅✅ Provider Outreach and Education (POE) department educates providers submitting claims
Prepayment review - ✅✅ Providers with identified problems may be placed on prepayment review, in which a selection of their claims undergo MR before the MAC authorizes payment. Once providers reestablish the practice of billing correctly, Prepayment review ends
Postpayment review - ✅✅ Contractors perform postpayment claim reviews most commonly by using statistically valid sampling. Sampling allows estimation of an underpayment or overpayment (if one exists) without requesting all records on all claims from providers. CERT Program - ✅✅ Performed by CERT Review Contractor (RC) and CERT Statistical Contractor (SC) CMS must calculate the - ✅✅ National Medicare FFS improper payment rate.
CERT randomly selects a - ✅✅ Statistically valid sample of processed Medicare FFS claims, and requests medical documentation from the provider or supplier that
submitted the sampled claim.
CERT performs a complex - ✅✅ Medical Review of the claim and the supporting
documentation to determine whether the claim was paid appropriately according to
Medicare coverage, payment, coding, and billing rules.
CERT - ✅✅ Comprehensive Error Rate Testing
CMS calculates a national Medicare FFS improper payment rate and improper payment rates by service type to - ✅✅ Accurately measure the performance of the
Macs and gain insight into the causes of error. CMS publishes the results of these reviews annually.
12.1% - ✅✅ # of improper Medicare Fee-For-Service claim payments, according to Federal Government.
FFS - ✅✅ Fee-For-Service
Prepayment Review - ✅✅ Review of claims prior to payment. Prepayment reviews result in an initial determination.
Postpayment Review - ✅✅ Review of claims after payment. May result in either no change to the initial determination or a revised determination, indicating an underpayment or overpayment.
Underpayment - ✅✅ A payment a provider receives under the amount due for services furnished under the Medicare statute and regulations.
Overpayment - ✅✅ A payment a provider receives over the amount due for services furnished under Medicare statutes and regulations
5 Common reasons for overpayment are: - ✅✅ 1.Billing for excessive and subsequent payment of the same service or claim. 2. Duplicate submission and payment for same service or claim
3. Payment for excluded or medically unnecessary services. 4. Payment for services in setting not appropriate to patient’s needs or condition
5. Payment to an incorrect payee.
MACs - ✅✅ Medicare Administrative Contractors
MAC Responsibilities - ✅✅ Process claims from physicians, hospitals, and other health care professionals, and submit payment to those providers according to Medicare rules and regulations (including identifying under- and overpayments).
ZPICs - ✅✅ Zone Program Integrity Contractors
PSCs - ✅✅ Program Safeguard Contractor
ZPICs/PCSs - ✅✅ Perform investigations that are unique and tailored to specific circumstances and occur only in situations where there is potential fraud, and take appropriate corrective actions
SMRC - ✅✅ Supplemental Medical Review Contractor
SMRC Responsibilities - ✅✅ Conduct nationwide medical review as directed by CMS (includes identifying underpayments and overpayments
Medicare FFS Recovery Auditors - ✅✅ Review claims to identify potential underpayments and overpayments in Medicare FFS, as part of the Recovery Audit Program
Zone 6 - ✅✅ All PSCs transitioned to ZPICs with the exception of Zone 6
While all contractors focus on a specific area, - ✅✅ Each contractor conducting a claim review must apply all Medicare policies to the claim under review. Additionally, once a claim is reviewed, a different contractor should not reopen it. Therefore, it is important when conducting claim reviews, contractors review each claim in its entirety.
Claim Review Programs - ✅✅ There are 5 claim review programs
NCCI Edits - ✅✅ National Correct Coding Initiative Editor
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