CMS Pub. 100-08, ch. 3, § 3.7.2

This section applies to MACs.

The MACs have the discretion to develop and issue comparative billing reports in the

following three (3) situations:

1. Provider-specific CBRs for providers with aberrant billing patterns.

The MACs have the discretion to give provider-specific comparative billing reports to

providers with the highest utilization for the services they bill in order to address

potential over-utilization. The MACs have the discretion to send the CBRs based

solely on data analysis, without further review or CBRs may be included in the

feedback and notification information issued as a result of probe and targeted medical

review. These reports shall provide comparative data on how the provider varies

from other providers in the same specialty payment area or locality. MACs should not

charge a fee for providing these reports.

2. Provider-specific or specialty-specific CBRs requestors.

To provide good customer service, MACs have the discretion to provide specific

reports to providers or provider associations who request such a report. They may

charge a fee for providing these discretionary reports. However, any money collected

shall be reported as a credit in the appropriate activity code or the applicable SOW

section and be accompanied with a rationale for charging the fee. Revenues collected

from these discretionary activities shall be used only to cover the cost of these

activities, and shall not be used to supplement other MAC activities. If the MACs

choose to make such reports available, the MACs shall describe on their Web site the

mechanism by which a provider or provider association can request the report and

state the associated fee.

3. CBRs for service-specific problems

When widespread problems are verified, MACs shall refer that information to their

POE department for possible Web site posting. For example, data analysis may

reveal that home health providers in a particular state bill three (3) times more of a

particular code than do home health providers in other surrounding states. The MACs

shall not charge a fee for posting these reports.

The MACs shall ensure that POE staff has ready access to copies of all MR provider

notification and feedback letters so that they will have this information available in

the event that a provider contacts POE requesting education. If the problem identified

by MR is of medium or high priority, the MAC shall make a priority referral to POE,

alerting POE staff to the degree of severity and educational need.