CMS Pub. 100-08, ch. 7, § 7.1.2.5

For each prioritized problem, the MAC shall develop a comprehensive plan of MR

activities and other improper payment interventions using the Progressive Corrective

Action (PCA) process. The MAC shall develop multiple tools to effectively address

identified problems. The scope and severity of the identified problems shall determine the

MR activities and improper payment interventions needed to successfully address the

problems.

The MR activities and improper payment interventions shall be tailored to the nature of

the problem. Existing interventions that have proven effective in reducing improper

payments shall be used as one basis for the implementing of MR activities and other

improper payment interventions. The effectiveness of existing MR activities and other

improper payment interventions shall be explained in discrete figures and/or improper

payment rates.

The MAC shall include an estimated date of implementation for each planned MR

activity and improper payment intervention.

The MR activities and improper payment interventions may include, but are not limited

to:

• MR Activities

• Provider or service-specific probes

• Targeted medical reviews (TMRs)

• Notification letters

• POE priority referrals

• Automated denials based on local coverage determinations (LCDs)

• Edit modifications

• Post-payment and statically valid random sampling (SVRS)

extrapolation

• Development or revisions of LCDs

• Probe review education

• POE activities

• Recalcitrant provider process

The MAC shall describe the process for provider selection for MR activities and other

improper payment interventions. For example, the MAC may describe review criteria in

the following manner: “Providers whose denied claims represent over x percent of the

dollar amount reviewed will be placed on a prepay review or providers who have a

provider error rate > x percent will be placed on an x percent prepay review.”

If initial MR activities and improper payment interventions are insufficient to improve

the provider’s billing behavior, a priority referral to POE for potential intervention may

be necessary. A POE priority referral indicates to the POE department that this is a

problem which MR has determined will likely require further educational intervention.

Through communication with POE, it is determined that MR activities, improper

payment interventions and POE educational efforts have not effectively resolved the

problem, a referral to the Unified Program Integrity Contractors (UPIC), Recovery

Auditor or the recalcitrant process may be indicated.

If an improper payment intervention is to refer the provider to another entity, i.e.,

Recovery Auditor, UPIC, or Quality Improvement Organization (QIO), the MAC shall

have backup MR activities or improper payment interventions if the referral is not

accepted by the other entity.

The MR department shall employ an effective follow-up process that ensures appropriate

resolution of the issue. If provider billing aberrances continue, the MAC shall use

information obtained via consultation with other areas of the MAC which shall include

the POE department to develop a revised comprehensive plan of MR activities and other

improper payment interventions using the PCA process. This plan may involve increases

in MR prepay review or conducting Statistical Sampling for Overpayment Estimation

(SSOE). As issues are successfully resolved, the MAC shall continue to address other

program errors/vulnerabilities identified on the prioritized problem list.

The MAC MR department shall have a system to track all referrals to POE, medical

review activities, and improper payment interventions used to address identified

problems. The MAC MR shall work with POE to develop an effective tracking system

for referred problems. The Contractor shall track all contacts made by their MR unit with

providers, UPICs, and Recovery Auditors during the course of medical review.