Part B Legacy Medical Review
The Medical Review function, as described in §1842(a)(2)(B) of
the Social Security Act, requires Medicare carriers to apply "safeguards
against unnecessary utilization of services furnished by providers."
These safeguards include prepayment and postpayment claim reviews
to identify inappropriate, medically unnecessary, or excessive services.
Medicare carriers determine whether patterns of claims submission
and payment indicate potential problems and then must take steps
to correct the problem billing activities. Through the Medical Review
Progressive Corrective Action (PCA) program of the Centers for Medicare
& Medicaid Services (CMS), carriers detect potential billing
errors and supply providers with feedback and education to correct
those errors. WPS believes that providers and suppliers want to correctly bill their services, and will do so if given the opportunity and proper education.
Principles of PCA
- Analyze Data
- Test hypotheses
- Prioritize and target workload
- Collect money when errors are identified
- Provide focused provider feedback and education
- Refer possible fraud or abuse issues to the appropriate Program Safeguard Contractor (PSC) for Benefit Integrity.
