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CMS Oversight And Review Programs

The Centers for Medicare & Medicaid Services (CMS) are required to take steps to ensure the Medicare Trust Fund does not make payments that are inappropriate, fraudulent, or incorrect. In order to protect the resources of the Medicare Trust Fund, CMS implements various programs and procedures to review, analyze, and evaluate providers’ billing and payments. Many of these review programs outsource the evaluation and reporting on billing and payments to third-party Medicare Contractors. Below are some of the most important CMS oversight and review programs that healthcare providers should know about.

Targeted Probe And Educate Program

The Centers for Medicare and Medicaid Services Targeted Probe and Educate (TPE) program functions to reduce claim denials and appeals through individualized review of a provider or supplier’s selected claims. Typically, between 20 and 40 claims are selected for review. Then, the Medicare Administrative Contractor (MAC) reviews the selected claims to identify any errors. Common claim errors include:

  • Failure to include the signature of the certifying physician
  • Documentation that fails to meet medical necessity
  • Encounter notes that do not support all elements of eligibility
  • Missing or incomplete initial certifications or recertifications

After the review, the MAC notifies the provider or supplier of errors in the reviewed claims and provides one-on-one education to remedy errors.

If your organization has received a TPE notice, it is best to consult with an experienced CMS audit lawyer to assist in the claims production to the MAC.

Comprehensive Error Rate Testing

The Centers for Medicare and Medicaid Services aims to reduce payment errors through the Comprehensive Error Rate Testing (CERT) program. CMS calculates the Medicare Fee-for-Service (FFS) improper repayment rate through CERT.

CERT evaluates a stratified sample of randomly selected claims to ensure claims paid by Medicare were properly payable and to verify compliance with Medicare’s coding and billing rules. The typical sample size reviewed through CERT is approximately 50,000 claims submitted to Part A/B Medicare Administrative Contractors (MAC) and Durable Medical Equipment MACs (DMACs).

If the reviewed claims do not meet Medicare criteria and requirements, or if the provider fails to submit medical records in support of the billed claim, the claim may be counted as an improper payment and may be recouped from a provider or supplier’s current Medicare revenues.

Medicare Drug Integrity Contractors

The Centers for Medicare and Medicaid Services utilizes the Medicare Drug Integrity Contractors (MEDICs) to oversee audit, anti-fraud and abuse efforts in the Medicare Advantage and Prescription Drug Programs.

MEDIC oversight activities include complaint investigations, data analysis to evaluate inappropriate activity, referral of cases to appropriate law enforcement or administrative action, and conducting audits.

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