RG – MEDICAL REVIEW/AUDITS
CMS Review Contractor Directory
The Review Contractor Directory – Interactive Map allows you to access state-specific CMS contractor contact information. You may receive correspondence from one or several of these contractors in your state. They may request medical records from you, as they perform business on behalf of CMS. You can use this website to access their contact information including emails, phone numbers, and websites.
MEDICAL REVIEW CONTRACTORS
Medical Administrative Contractors (MAC)
A Medicare Administrative Contractor (MAC) is a private health care insurer that has been awarded a geographic jurisdiction to process Medicare Part A and Part B (A/B) medical claims or Durable Medical Equipment (DME) claims for Medicare Fee-For-Service (FFS) beneficiaries. CMS relies on a network of MACs to serve as the primary operational contact between the Medicare FFS program and the health care providers enrolled in the program. MACs are multi-state, regional contractors responsible for administering medical review and redetermination requests (1st stage appeals process).
-
-
- Review medical records for selected claims. Requests are often referred to as ADRs (Additional Development Request).
- Coordinate with CMS and other FFS contractors
- Respond to provider inquiries
- Educate providers about Medicare FFS billing requirements
- Establish local coverage determinations (LCDs)
-
MAC websites address their specific medical review requirements and provide resources and guidance on the process.
Comprehensive Error Rate Testing (CERT)
The CMS CERT program measures improper payments in the Medicare Fee-For-Service (FFS) program. The CERT program is not a measure of fraud. Since the CERT program uses random samples to select claims, reviewers are often unable to see provider billing patterns that indicate potential fraud when making payment determinations. The CERT program does not, and cannot, label a claim fraudulent.
-
-
- The CERT Documentation randomly selects claims, and sends a letter to the provider, requesting specific documentation for the services billed.
- Providers are required to respond to all CERT requests for additional information within the time-frame outlined in the request letter.
- Providers have the same appeal rights under CERT they would have under traditional Medicare.
-
Additional information
Unified Program Integrity Contractors (UPIC)
UPICs perform numerous functions to detect, prevent, and deter specific risks and broader vulnerabilities to the integrity of the Medicare and Medicaid programs. They will also coordinate activities with CMS and other agencies at the Federal, state, and local government levels, as well as with other CMS partners and contractors.
Qlarant Integrity Solutions, LLC.
Recovery Audit Program
The Medicare Fee-for-Service (FFS) Recovery Audit Program’s mission is to identify and correct Medicare improper payments through the efficient detection and collection of overpayments made on claims of health care services provided to Medicare beneficiaries, and the identification of underpayments to providers so CMS can implement actions to prevent future improper payments in all 50 states. Claims are reviewed on a post payment basis.
Supplemental Medical Review Contractor (SMRC)
Centers for Medicare & Medicaid Services (CMS) contracts with a Supplemental Medical Review Contractor (SMRC) to help lower improper payment rates and protect the Medicare Trust Fund. The SMRC conducts nationwide medical reviews of Medicaid, Medicare Part A/B, and DMEPOS claims to determine whether claims follow coverage, coding, payment, and billing requirements. The focus of the medical reviews may include vulnerabilities identified by CMS data analysis, the Comprehensive Error Rate Testing (CERT) program, professional organizations, and Federal oversight agencies. At the request of CMS, the SMRC may also carry out other special projects to protect the Medicare Trust Fund.
Payment Error Rate Measurement (PERM)
The PERM measures improper payments in Medicaid and CHIP and produces error rates for each program. The error rate is not a “fraud rate” but simply a measurement of payments made that did not meet statutory, regulatory, or administrative requirements.
Current Medical Review Audits
Awareness of what medical review audits is important. Here’s how to keep current.
-
-
- Watch NHPCO updates through Newsbriefs.
- Subscribe to updates through your MAC.
- Visit Recovery Auditor websites.
-
Subregulatory Guidance
-
-
- Medicare Program Integrity Manual Chapter 3 - Verifying Potential Errors and Taking Corrective Actions Medicare Program Integrity Manual (cms.gov)
- Medicare Program Integrity Manual Chapter 12 – The Comprehensive Error Rate Testing Program
-
Other Resources:
Cross Reference
NHPCO Advocacy
Alerts/Newsbriefs/Newsline
(Nothing applicable at this time)
Education
-
-
- Webinars/On-Line Learning/Conferences
(Nothing applicable at this time) - Podcasts
- Webinars/On-Line Learning/Conferences
-
NHPCO Member Resources and Compliance Guides
(Nothing applicable at this time)
Regulations
(Nothing applicable at this time)
Subregulatory Guidance
CMS has resources about how the Targeted Probe and Educate program helps providers reduce claim denials and appeals through one-on-one education. The TPE webpage has resources, including:
-
-
- A five-minute video that explains the TPE process
- One-pager about the program to download and share
- Q&As
-
Other Resources
Cross Reference
Alerts/Newsbriefs/Newsline
(Nothing applicable at this time)
Hospices have the right to appeal claim determinations made by Medicare Contractors, CERT, or Recovery Auditors. The purpose of the appeals process is to ensure the correct adjudication, or processing, of the claim. There are 5 levels of the appeals process and each appeal process has specific timelines and requirements.
-
-
- Redetermination
- Reconsideration (Qualified Independent Contractors/QIC)
- Administrative Law Judge (ALJ)
- Departmental Appeals Board (DAB) Review
- Federal Court (Judicial) Review
-
NHPCO Member Resources and Compliance Guides
(Nothing applicable at this time)
Subregulatory Guidance
-
-
- Medicare Claims Processing Manual Chapter 34 – Reopening and Revision of Claim Determinations and Decisions
- Medicare Claims Processing Manual Chapter 29 - Appeals of Claims Decisions
- The Medicare appeals process; Five Levels to Protect Providers, Physicians, and Other Suppliers
- Complying with Medicare Signature Requirements (cms.gov)
- Qualified Independent Contractor – Second Level of Review
-
Other Resources
-
-
- QIC Part A West Maximus, Inc.
- QIC Part A East (c2cinc.com)
- Part B QICs Jurisdictions
-
Cross Reference