CMS Pub. 100-08, ch. 7, § 7.1.2.4

The MAC shall develop a prioritized problem list after data analysis has been completed.

The MAC shall list five to ten prioritized problems, for each appropriate claim type

(Durable Medical Equipment, Prosthetics, Orthotics, & Supplies (DMEPOS), Part A, Part

B, and Home Health and Hospice (HHH)), selected for inclusion in the IPRS.

The MAC shall describe the method, criteria, and data analysis used to prioritize the

problem list. The MAC shall consider their resources and other operational areas of the

MAC with similar goals when developing the prioritized problem list.

The prioritized problem list shall include the identified payment errors/vulnerabilities that

can be addressed through MR activities, POE, and other improper payment interventions.

The MR problems for the current contract year, as well as problems that are carried over

from the previous IPRS or SAR, shall be included. Any prioritized problems carried over

from a previous IPRS or SAR shall include an explanation. The MAC shall also include a

rationale if top errors identified by CERT are not included in the prioritized problem list.

Top errors would be the top service/claim types by projected improper payments within

the MAC’s jurisdiction and nationally.

The following requirements shall be included for each specific prioritized problem:

• Whether the prioritized problem is a new or a carry-over problem.

• Data source/analysis that led to the identification of the problem. The IPRS

shall identify the source of data that led to the identification of the problem for

inclusion in the IPRS.

• MAC-specific improper payment rate as measured by the CERT program

and/or the MAC. This information shall demonstrate how this problem

contributes to the MAC and national improper payment rates. The MAC shall

specify whether the improper payment rate was measured by the CERT program

or the MAC.

• Cause(s) of the problem. The IPRS shall identify the specific cause of the

error/vulnerability resulting in improper payments. Such causes may include, but

are not limited to, insufficient clinical documentation, incorrect coding,

unnecessary utilization, inadequate provider understanding of relevant CMS rules,

lack of medical necessity, or the rendering of services in the incorrect clinical

setting.

• Baseline measurement to be used for the purpose of assessing improvement.

The IPRS shall identify the baseline measurement that will be used for the

purpose of assessing improvement through time. This section shall also describe

the process for calculating the starting/baseline problem measurement (e.g., IPR,

claims denial rate, charges denial rate, provider error rate). An assessment of

progress towards accomplishment of the improvement goals cannot be made

unless the starting point/baseline problem measurement is known. For example,

an improvement goal to reduce the problem measurement or to improve provider

compliance with coverage requirements by a specific percentage without the

baseline or starting problem measurement does not enable measurement of

progress towards the improvement goal.

• Achievable and measureable improvement goals. The IPRS shall include

concrete improvement goals for each prioritized problem that are data-driven,

achievable, and measurable. The establishment of improvement goals will require

the MAC to use information from the MAC MR, data analysis, POE, and other

departments, as appropriate. CMS does not mandate the MAC to use any specific

improvement goal; however, selected improvement goals and MR activities and

improper payment interventions shall ultimately contribute to lowering the overall

improper payment rate and/or to an improvement in provider billing behavior.

The outcome shall be the reduction of the starting/baseline problem measurement

as listed in the specific improvement goal (e.g. improvement of provider

billing/provider error rate; number of providers removed from review due to

decrease in their error rate, reduction of error rate etc.). Specifically, this section

shall include:

o The timeframe to achieve the improvement goal.

o An explanation of progress or lack of progress towards accomplishment of

the improvement goal (when the improvement goal is carried over from the

previous IPRS or SAR).

o Parameters or thresholds for removing a provider/supplier from MR

activities or other interventions as it relates to the improvement goal.

o Evaluation methods that test the effectiveness and efficiency of MR

activities and other improper payment reduction interventions.