CMS Pub. 100-06, ch. 7, § 50.6

F – Control

Number

Control Objective – Medical Review (MR)

F.1 Contractor shall use the Program Integrity Manual (PIM)

guidelines, data analysis (prior year and most current) and Medical

Review (MR) results including Strategy Analysis Report (SAR),

and Comprehensive Error Rate Testing (CERT) results to develop

and update the Improper Payment Reduction Strategy (IPRS). The

problem-focused outcome-based IPRS report shall address provider

specific problems, and service-specific problems only in the rare

circumstance it is approved by CMS. The IPRS shall focus its

medical review activities toward the goal of reducing the claims

improper payment rate. All work performed by the MR unit shall be

identified in the IPRS and targeted based on the contractor’s

prioritized problem list or as directed by CMS.

F.2 Contractor shall budget and perform the MR workloads throughout

the year as established in the IPRS. MACs shall report workload

volume, and costs associated with MR activities in CMS Analysis,

Reporting, and Tracking (ART) systems or as directed by the COR.

MACs shall explain any significant fluctuations in workload or

costs in the Monthly Status Report and SAR.

F.3 Contractor shall perform data analysis continuously to identify

potential problems such as aberrant billing practices, potential of

over-utilization areas, and changes in patterns of care to target

medical review activities to reduce the claims improper payment

rate. Data from a variety of sources must be used for data analysis.

At a minimum, sources include: contractor internal data; CMS

program vulnerability alerts such as Quarterly Vulnerability

Technical Direction Letters that require corrective action reporting,

FATHOM/PEPPER and other comparative billing reports; results

from medical review studies performed by specialty MR or Program

Integrity contractors; and other national or regional sources such as

Office of Inspector General (OIG) reports, Government

Accountability Office (GAO) reports, enrollment data, and fraud

alerts.

F.4 Contractor shall ensure that effective MR edits are developed and

implemented as a result of data analysis findings and policies. The

effectiveness of each MR edit shall be analyzed and measured by

tracking the denial rate, appeals reversal rate, basis of the appeals

reversal, and the dollar return on the cost of operationalizing the edit

(savings), and success of edit towards billing behavior correction.

MR edits shall be modified, deleted, or deactivated when they are

determined to no longer be effective.

F – Control

Number

Control Objective – Medical Review (MR)

F.5 Contractor shall utilize the Progressive Corrective Action (PCA)

process and Targeted Probe and Educate (TPE) process, in

accordance with the Pub. 100-08 and CMS instructions, to drive

MR activity (i.e., data analysis, claims review, medical review

education).

PCA would only apply to MR activity performed before TPE was

started by the MAC and/or in a CMS approved MR activity.

F.6 Contractor shall be capable of identifying the status of each claim

subjected to medical review at any time (and all claims must be

processed timely for closure in accordance with Pub. 100-08

instructions).

F.7 Control number F.7 reserved. Control not in use as of IOM revision

number 278.

F.8 The MR unit shall effectively collaborate with Provider Outreach

and Education (POE) by referring educational needs that will

address existing program vulnerabilities and emerging problems

identified during the MR process conducted throughout the fiscal

year.

F.9 Contractor shall implement and utilize a Provider Tracking System

(PTS) to track all informational provider contacts made by medical

review and all educational referrals submitted to POE and external

organizations.

F.10 Contractor shall ensure that there is adequate internal networking

and sharing of information, and appropriate collaborative actions are

taken as a result, between MR and other business functions such as

Appeals, Audits, POE, and inquiries and external organizations such

as the Zone Program Integrity Contractors (ZPIC), Unified Program

Integrity Contractors (UPIC), Recovery Auditors, and Quality

Improvement Organizations (QIOs).

F.11 Contractor shall apply quality assurance processes to all elements of

the MR Strategy and to all aspects of program management, data

analysis, edit effectiveness, problem identification, and claim

adjudication.

F.12 Contractor shall effectively comply with all of the MR requirements

of the Joint Operating Agreement (JOA) with the PSCs/ZPICs and

Recovery Auditors, and other entities as directed by CMS.

F – Control

Number

Control Objective – Medical Review (MR)

F.13 Contractor shall institute a corrective action reporting process for

claims-specific errors and vulnerabilities in accordance with PIM

3.7.5. For each issue, MACs shall report interim actions, final actions,

and action dates.

End Section 50.6 – F Controls – Medical Review (MR): Back to Table of Contents