Medical Review and Education

To prevent improper payments and protect the Medicare Trust Fund, Medicare contractors operate the medical review program. Medical reviews involve the collection and clinical review of medical records and related information to ensure that payment is made only for services that meet all Medicare coverage, coding, billing, and medical necessity requirements.

What is the purpose of the medical review program?

Medical reviews identify errors through claims analysis and/or medical record review activities. Contractors use this information to help ensure they provide proper Medicare payments (and recover any improper payments if the claim was already paid). Contractors also provide education to help ensure future compliance.

A Medicare contractor may use any relevant information they deem necessary to make a prepayment or post-payment claim review determination. This includes any documentation submitted with the claim or through an additional documentation request. (See sources of Medicare requirements, listed below).

Who conducts the medical reviews?

Medicare Fee-for-Service (FFS) reviews are conducted by Medicare Administrative Contractors (MACs), the Supplemental Medical Review Contractor (SMRC), Recovery Audit Contractors (RACs), and others.

What sources of information do contractors use when selecting claims and subjects for medical reviews?

Medical review activities, such as the Targeted Probe and Educate program, are based on data analysis and other findings indicative of a potential vulnerability. This might include findings from the Comprehensive Error Rate Testing (CERT) Contractor, the Office of Inspector General (OIG), the Government Accountability Office (GAO), or the Recovery Audit Contractors (RACs).

Where can providers find more information on Medicare requirements?

Medicare medical review contractors are required to follow CMS coverage instructions, as well as pertinent coding and billing materials. Coverage criteria may be outlined in statute and/or regulation, and may be further defined in:

• National Coverage Determinations (NCDs): Medicare coverage is limited to items and services that are reasonable and necessary for the diagnosis or treatment of an illness or injury (and within the scope of a Medicare benefit category). The NCDs are developed by CMS to describe the circumstances for which Medicare will cover specific services, procedures, or technologies on a national basis. Medicare Contractors are required to follow NCDs. If an NCD does not specifically exclude/limit an indication or circumstance, or if the item or service is not mentioned at all in an NCD or in a Medicare manual, it is up to the Medicare contractor to make the coverage decision. NCDs are accessible via the Medicare Coverage Database or the Medicare National Coverage Determination Manual (PDF).
• Local Coverage Determinations (LCDs): In the absence of a national coverage policy, an item or service may be covered at the discretion of the Medicare Contractors based on a local coverage determination (LCD). LCDs are accessible via the Medicare Coverage Database.
• CMS' Manuals: CMS manuals (such as the Benefit Policy, Claims Processing, and Program Integrity Manuals) provide further interpretative medical review guidance for medical review activities.

Who manages Medicare medical review contractors?

CMS' Center for Program Integrity (CPI) oversees Medicare medical review contractors. CPI conducts contractor oversight activities such as:

• Providing broad direction on medical review policy
• Reviewing and approving Medicare contractors' annual medical review strategies
• Facilitating Medicare contractors' implementation of recently enacted Medicare legislation
• Facilitating compliance with current regulations
• Ensuring Medicare contractors' performance of CMS operating instructions
• Conducting continuous monitoring and evaluation of Medicare Contractors' performance in accord with CMS program instructions as well as contractors' strategies and goals
• Providing ongoing feedback and consultation to contractors regarding Medicare program and medical review issues