CMS Pub. 100-08, ch. 7, § 7.1.2.3

The MAC shall target their efforts on those services, items, and providers/suppliers in their

jurisdiction that pose the greatest financial risk to the Medicare Trust Fund and that represent

the best investment of resources to reduce the national improper payment rate (IPR).

The first step in creating or updating an IPRS is to establish a priority-setting process to

assure MR activities and other interventions are focused on areas with the greatest potential

for improper payments. The MACs shall analyze and gather data from a variety of sources

for this purpose. The MACs’ Comprehensive Error Rate Testing (CERT) findings shall

be used as a primary source of data. However, CERT findings are only one indication of

where to focus and shall not be relied upon as the single source of data information. The

MAC shall consult a variety of resources. Examples of other appropriate resources

include, but are not limited to:

• Recovery Auditor-identified problem

• Comparative billing reports (CBRs)

• Office of Inspector General (OIG) or Government Accountability Office (GAO)

reports

• MAC data analysis on a specific benefit, diagnostic/procedure code, or place of

service. This analysis shall include an identification of the specific cause of

improper payments

• Evaluation of utilization or probes

The MAC shall provide detailed information of the data analysis conducted for purposes

of developing the IPRS. The data analysis plan shall list the data resources used in

developing the prioritized problem list. If a prioritized problem is carried over from a

previous IPRS or Strategy Analysis Report (SAR) the MAC shall provide information

regarding the current, updated data analysis conducted to ensure that the prioritization of

the problem is accurate and current. If a former prioritized problem is not carried over

from a previous IPRS or SAR, an explanation and data shall also be provided.