Myths versus Reality

Medical Review Mission

To work with the Medicare physician/provider community to identify claims submission issues through data analysis, and to educate the physician/provider on the issues identified, conduct medical review of claims as needed, and implement the progressive corrective action (PCA) process.

M: A medical review request leads to a benefit integrity referral.

R: Medical review requests seek documentation as the first phase of our educational contact. Normally, the information requested is to support billing the service or the level of service. Many times this documentation is the information needed to respond with findings to the physician/provider. Medicare refers very few medical review cases to Benefit Integrity.

M: Medical review is a time consuming process where I'm being questioned about what I believe to be appropriate medical care.

R: Medical review is an educational process where the contractor, through data analysis, works to identify, understand, and influence change in inappropriate billing practices to ultimately reduce the Medicare fee-for-service paid claims error rate.

M: Now that Medicare has my name, I'll be sending records to them for months/years.

R: The average review lasts 3 to 9 months, including the period where follow-up statistical reviews are conducted in order to evaluate the effectiveness of the education, with a goal of removal of the provider from audit. With the Progressive Corrective Action process, the number of records requested is reduced significantly. Probe reviews will consist of no more than 20-40 claims; however, if the Probe results warrant an Expanded Targeted Medical Review, a larger volume of claims will be audited.

M: I've been subject to random reviews that are not based on anything concrete.

R: Random reviews are no longer part of the medical review process. This was a CMS requirement, which ended as of 10/1/01.

M: Medicare targets certain physicians or physician/provider specialties. (This myth is very similar to the myth that states, "Medicare uses its data to target specific procedures or physician/providers based on opinion, physical location, or specialty.") Our response applies to both.

R: We use data analysis and CERT results to identify areas with significant existing and emerging claim payment error rates.

M: There is little opportunity for my opinion to be heard relative to Medicare Medical Policy.

R: All Medicare Part B Carriers are required to maintain a Carrier Advisory Committee. This committee is made up of physicians/clinicians and others who represent the interests of all medical specialties. These representatives are not selected by WPS, but by the individual societies. The members of the CAC review and comment on all draft Local Coverage Determinations (LCD). Also, the CAC members are usually involved early on in the development of new LCDs that particularly affect their specialties. Typically they contact other members of their specialty for input. This mechanism provides an opportunity for all Medicare physician/providers to put forth opinions/insights to their specialty society so that it can be considered in new Medicare policies.

In addition, your representative in the CAC is a good vehicle to transmit concerns to WPS. If you believe that there is a problem with issues, contacting your representative is an excellent idea. This way, your specialty can tell if there is a generalized problem that needs resolving. For example, in the past the CAC representatives from cardiology and dermatology informed us about problems with our processing echocardiography claims and actinic keratosis claims respectively. We realized that this was not merely an issue of one or two cardiologists/dermatologists not billing correctly. We met with the cardiology and dermatology communities and corrected this error with our computer system

M: Carrier Advisory Committee is the only way that input is received for Local Coverage Determinations.

R: To assure the development of LCD occurs through a public and open process, WPS Medicare sponsors open meetings (3 times a year), specific to the draft policies. These open meetings allow for the submission of scientific and other information from members of the general public relating to the draft policies. Draft Local Coverage Determinations are posted on this website, and any providers may comment on these drafts directly on the website. The Carrier Medical Directors consider all comments. Also, comments can be emailed or mailed.

Finally, there is a LCD Reconsideration Process. If you feel that an existing LCD needs changes, you can ask for a LCD reconsideration. The method is also found on our website by selecting the Policy tab in the top navigation bar.

Page Last Updated: Wednesday, 05-Oct-2011 12:47:53 CDT