Medical Review

Audio/Visual Introduction

The Centers for Medicare & Medicaid Services (CMS) states the following regarding Medical Review (MR):

The goal of the medical review program is to reduce payment error by identifying and addressing billing errors concerning coverage and coding made by providers. To achieve the goal of the MR program, contractors:

Proactively identify potential billing errors concerning coverage & coding made by providers through analysis of data (e.g., profiling of providers, services, or beneficiary utilization) and evaluation of other information (e.g., complaints, enrollment and/or cost report data);
Take action to prevent and/or address the identified error. Errors identified will represent a continuum of intent, and;
Publish local medical review policy to provide guidance to the public and medical community about when items and services will be eligible for payment under the Medicare statute.