CMS Pub. 100-08, ch. 3, § 3.7.5

A. General

This section applies to MACs.

The CMS will provide information to the MACs regarding CMS Recovery Audit

Contractor (RAC), and OIG-identified issues via Technical Direction Letters (TDLs).

The TDLs will be sent to the MACs on a quarterly basis. Each MAC shall report

corrective actions by the dates stated in the TDLs.

B. Corrective Action Reporting on CMS and OIG-Identified Issues

The CMS will provide MACs with a list of issues on an Excel spreadsheet template

(Corrective Actions Taken on CMS and OIG-Identified Issues). These issues may be

uncovered by the RAC, OIG audits, internal CMS analysis, or other means. The MACs

shall review the spreadsheet, type precise responses on the template (see interim and final

reportable action statement samples below), and upload the excel file or flat file to the

RAC Data Warehouse (RAC DW).

For each of the issues, MACs shall report interim actions, final actions, and action dates

(see interim and final reportable action statement examples below). The common factor

between all reportable actions is quantifiability. The distinguishing factor between the

two types of reportable actions is intervention implementation. Interim reportable actions

generally indicate in-progress reviews of issues prior to the initiation of final actions.

Final reportable actions indicate specific interventions completed to prevent future

improper payments.

Examples of interim reportable action statements:

• MAC is planning a 50% post-payment review (to be performed between

08/01/2014 – 08/31/2014) of 200 claims (with dates of service between

01/01/2012 – 12/31/2012).

• MAC performed a 100% pre-payment review for DRG numbers ### – ### on

02/14/2014 (with dates of service between 01/01/2012 – 12/31/2012).

• MAC performed a pre-payment widespread review using a 100 claim probe on

03/26/2014 (with dates of service between 01/01/2012 – 12/31/2012).

• MAC performed a provider-specific pre-payment review on 04/17/2014 (with

dates of service between 01/01/2012 – 12/31/2012).

• Due to resource limitations, not yet able to fully research issue (with dates of

service between 01/01/2012 – 12/31/2012).

Examples of final reportable action statements:

• MAC held a provider seminar for 500 chiropractors regarding documentation

requirements on 11/12/2013.

• MAC published an article regarding billing for nebulizer drugs on 02/27/2014 that

explained the coverage policy for nebulizer drugs.

• MAC installed an automated edit and validated functionality on 03/19/2014 for

codes ### – ###.

o If readily available, please provide edit effectiveness as defined in PIM

section 3.7.3.1 – Evaluation of Prepayment Edits. <Please insert cost

savings and number or percentage of claims denied.>

• MAC performed a provider -specific review resulting in a provider education

activity. <Comparative Billing Report, letter, one-on-one telephone

explanation,…>…on 05/19/2014.

• Based on analysis, this is not an issue within jurisdiction X.

Interim and final reportable action statement rationales:

• In the additional comments section of the TDL template, MACs shall provide

brief supplementary rationales for the reported actions. o For example, rationales

may state that analysis produced no significant findings due to low volume,

claims paid, lower risk and lower priority ranking when compared with other

issues.

• The MACs have the discretion to also utilize the additional comments section to

briefly explain pertinent background information regarding the MACs processes

for specific issues. The MACs may also utilize the space to communicate

suggestions for CMS to consider regarding possible future actions.

The MACs shall use the format (Corrective Actions Taken on CMS and OIG-Identified

Issues) located in Exhibit 18, section A for reporting purposes. The MACs shall use the

prescribed format, acceptable to the RAC DW. The MACs shall upload the file by the

date specified in the TDL. If the due dates fall on a weekend or a federal holiday, the

MAC shall upload the file on the closest business day after the weekend or holiday. A

TDL may occasionally provide an exception to the submission criteria described in the

PIM and the exception will be stated within the text of the memorandum.

Updates to previous reportable actions

The MACs shall keep CMS informed of any updates or changes to interim or final

reportable actions on top issues from past TDL responses. The format located in Exhibit

18, Section A will included a column titled ‘Updated Responses.’ The MACs shall enter

the following information, in a single cell, for each update:

• The New Issue number being updated

• The Issue Label

• The fiscal year and quarter that the responses were first provided

• The type of response originally provided [Interim or Final]

• The type of response being provided in the update [Interim or Final]

• The response statement in the format described above

The MACs should leave this section blank if they have no updates for the quarter.

C. Overpayment Recovery Reporting

The CMS will provide the MACs with specific claims information from Office of the

Inspector General (OIG) audits on a quarterly basis via TDLs. These specific claims have

not been reviewed by the OIG and overpayments have not yet been identified. The MACs

have the discretion to review these specific OIG-identified claims. The MACs shall

report overpayment recoveries pertaining to the specific OIG-identified claims to the

CMS on a quarterly basis. If the MAC does not plan on conducting review or cannot

conduct review on the specific OIG-identified claims, the MAC shall indicate that no

medical review will be conducted and shall also indicate the reason why no medical

review and/or overpayment recovery will be conducted on the particular claims set. The

reporting shall include the Medicare contractor number, the OIG audit number (e.g. A-

01-08-00528, OEI-01-04-0060) and the cumulative amount collected on the

overpayments resulting from the specific set of OIG-identified claims. The cumulative

amount shall include appeals. The CMS will indicate the “final reporting date” in the

reporting document when the recovery process has been completed for a specific set of

OIG-identified claims. CMS will indicate when the report shall be closed. The MACs

have the discretion to report on overpayments that have been referred or are uncollectable

at this time resulting from the specific set of OIG-identified claims.

The MACs shall submit their response to CMS on or before March 1, June 1, September

1, and December 1. If the due dates fall on a weekend or a federal holiday, the MACs

shall submit the report on the closest business day after the weekend or holiday. The

MACs shall submit their response in Excel via email to the CMS contact indicated in the

most recent TDL from CMS which includes the claim information and report number.

The MACs shall use the format titled “Overpayment Recovery on OIG Claims Format”

located in Exhibit 18 for reporting purposes. The MAC has the discretion to readjust the

format for use in Excel. The MAC shall complete all fields in the format except for the

one optional column. The MACs have the discretion to complete the column titled

“Overpayments referred or uncollectable (in dollars).”