Part B Legacy Medical Review

Home Provider Part B Medicare Areas MR/CERT

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

Myths versus Reality

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 only about 5 percent of 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 potentially influence change in abnormal billing practices and 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 new Progressive Corrective Action process implemented last year, the number of records requested is reduced significantly. Probe reviews will consist of no more than 40 claims; however, if the Probe results warrant an Expanded Probe 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 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. The members of the CAC review and comment on all Local Medical Review Policies (LMRP). This mechanism provides an opportunity for all Medicare physician/providers to put forth opinions/insights to their specialty society so that it can be taken to the CAC.
M:	Carrier Advisory Committee is the only way that input is received for Local Medical Review Policies.
R:	To assure the development of LMRP occurs through a public and open process, WPS 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 medical review policies are posted on this web site, and any providers may comment on these drafts. The Carrier Medical Directors consider all comments.
M:	Medicare can request records and documentation from me, but they will only tell me I was selected or the code I billed was selected.
R:	Medicare will inform you of the reasons you were selected for review, based on data analysis. We want you to know why your services or your physician/provider number surfaced through our data analysis process.
M:	Medicare uses its data to target specific procedures or physician/providers based on opinion, physical location, or specialty.
R:	Medicare uses national data to identify issues with specific procedures, specialties or physicians/providers. We then support the national statistics with regional data to confirm our finding before ever making our first contact/request.