(Medicare Program Integrity Manual)

This section applies to MACs.  Direct communication between the MAC and the provider is an essential part of solving problems.  This process is carried out through written communication or by telephone as a result of specific claims or a gr oup of reviewed claims.  The overall goal of providing notification and feedback is to ensure proper billing practices and appropriate consideration of coverage criteria so claims will be submitted and paid correctly.   The MACs shall include an offer to pr ovide individualized education in the notification letter along with contact information for POE. When inquiries are received in response to a provider notification or feedback letter, only responses to those inquiries directly related to a specific claim or group of claims reviewed on probe or targeted medical review shall be charged to medical review. This charge must be in the appropriate activity code or applicable SOW section for the type of review performed.   3.7.2 - Comparative Billing Reports (CBRs)  (Rev. 377, Issued: 05- 27-11, Effective: 06 -28-11, Implementation: 06- 28-11)  This section applies to MACs.  The MACs have the discretion to develop and issue comparative billing reports in the following three (3) situations :  1. Provider- specific CBRs for providers with aberrant billing patterns.   The MACs have the discretion to give provider -specific comparative billing reports to providers with the highest utilization for the services they bill in order to address potential over -utilization.  The MACs have the discretion to send the CBRs based solely on data analysis, without further review or CBRs may be included in the feedback and notification information issued as a result of probe and targeted medical review.  These repo rts shall provide comparative data on how the provider varies from other providers in the same specialty payment area or locality. MACs should not charge a fee for providing these reports.   2. Provider- specific or specialty -specific CBRs requestors.   To provi de good customer service, MACs have the discretion to provide specific reports to providers or provider associations who request such a report.  They may charge a fee for providing these discretionary reports.  However, any money collected shall be reporte d as a credit in the appropriate activity code or the applicable SOW section and be accompanied with a rationale for charging the fee.  Revenues collected from these discretionary activities shall be used only to cover the cost of these activities, and sha ll not be used to supplement other MAC activities.  If the MACs choose to make such reports available, the MACs shall describe on their Web site the mechanism by which a provider or provider association can request the report and state the associated fee.   3.  CBRs for service- specific problems   When widespread problems are verified, MACs shall refer that information to their POE department for possible Web site posting.  For example, data analysis may reveal that home health providers in a particular state bi ll three (3) times more of a particular code than do home health providers in other surrounding states.  The MACs shall not charge a fee for posting these reports.   The MACs shall ensure that POE staff has ready access to copies of all MR provider notifica tion and feedback letters so that they will have this information available in the event that a provider contacts POE requesting education.  If the problem identified by MR is of medium or high priority, the MAC shall make a priority referral to POE, alerting POE staff to the degree of severity and educational need.   3.7.3 - Evaluating the Effectiveness of Corrective Actions  (Rev. 10365; Issued: 10- 02-20; Effective: 08 -27-20; Implementation: 08 -27-20)  This section applies to MACs.  The MACs shall evaluate the effectiveness of their corrective actions on targeted providers or problem areas at least every three (3) months until there is evidence that the poor practice has been corrected. MACs shall establish a method to determine the disposition of educationa l referrals made to POE to ensure coordination of efforts and resolution of identified problems. MACs have the discretion to use the PTS to perform this function, but are not mandated to do so. MACs shall use the PTS to coordinate contacts with providers r egarding MR activities. MACs shall also coordinate this information with the UPICs to ensure contacts are not in conflict with fraud related activities.   3.7.3.1 - Evaluation of Prepayment Edits  (Rev. 721; Issued: 06- 09-17; Effective: 07 -11-17; Implementation: 07 -11-17)  This section applies to MACs.  The MACs shall develop prepayment edits based on the findings of data analysis, followed by identification and prioritization of identified problems. The MACs shall evaluate all service -specific and  provider -specific prepayment edits as follows:    Automated edits shall be evaluated annually, and   Non-medical record review or medical record review edits shall be evaluated quarterly.   The edit evaluations are to determine their effectiveness on the provi der or service area while assessing the effect of the edit tasks on workload.  The MACs shall consider an edit to be effective when it has a reasonable rate of denial relative to suspensions and a reasonable dollar return on cost of operation or potential to avoid significant risk to beneficiaries. The MACs shall revise or replace edits that are ineffective.  Edits may be ineffective when payments or claims denied are very small in proportion to the volume of claims suspended for review.  It is appropriate to leave edits in place if sufficient data are not available to evaluate effectiveness, for instance, a measurable impact is expected, or a quarter is too brief a time period to observe a change.  The MACs shall analyze prepayment edits in conjunction with data analysis to confirm or re -establish priorities.  The MACs should replace existing effective edits to address problems that are potentially more costly, if appropriate.  3.7.3.2 - Evaluating Effectiveness of Established Automated Edits  (Rev. 10365; Is sued: 10 -02-20; Effective: 08 -27-20; Implementation: 08 -27-20)  This section applies to MACs.  MACs shall consider the following factors when looking at edit effectiveness for established automated edits:    Time and staffing needs for review and appeal reviews. MACs shall implement mechanisms (e.g., manual logs, automated tracking systems) to allow the appeals unit to communicate to the MR unit information such as when denial categories are causing the greatest impact on appeals, the outcome of th e appeal,  and   MACs shall maintain and make available to the appropriate CMS staff documentation demonstrating that they consider appeals in their edit evaluation process; and specificity of edits in relation to identified  problem(s).   The MACs should note that even an automated edit that results in no denials may be effective as long as the presence of the edit is not preventing the installation of other automated edits. The MAC shall provide the claims data necessary to the UPIC to evaluate the effectiveness of edits implemented at UPIC request. The MACs shall provide this report on a monthly basis by the 15th business day of each month. This requirement could also be met by the UPICs retrieving claim data necessary directly from the EDC if avai lable.   A. Edit Effectiveness for all Other Edits   The MACs shall consider the following factors when looking at edit effectiveness for all other edits:    Time and staffing needs for review and appeal reviews. MACs shall implement mechanisms (e.g., manual logs , automated tracking systems) to allow the appeals unit to communicate to the MAC MR unit and the UPIC just specific to UPIC edits information such as which denial categories are causing the greatest impact on appeals, and the outcome of the appeal. MACs shall maintain and make available to CMS documentation demonstrating that appeal outcomes are considered in their edit evaluation process;    Specificity of edits in relation to identified  problem(s);    Demonstrated change in provider behavior, i.e., the MAC c an show a decrease in frequency of services per beneficiary, the decrease in the number of beneficiaries receiving the services, the service is no longer billed, or another valid measure can be used to reflect a change in provider behavior over  time;   Impact of educational or deterrent effect in relation to review costs;  and   The relative priorities or competing edits in terms of the number  of claims/days/charges.   The MACs shall test each edit before implementation to verify that the edit accomplishes the objective of efficiently selecting claims for review and to determine the edits impact on workload.  3.7.3.3 - Evaluation of Postpayment Review Effectiveness  (Rev. 10365; Issued: 10- 02-20; Effective: 08 -27-20; Implementation: 08 -27-20)  This section applies to MACs.  The MACs shall determine if any other corrective actions are necessary such as:    Uncovering potential fraud in the course of MR postpayment review activities. The MR unit shall refer these cases to the UPIC. If it is believed that the overpayment resulted from potential fraud, a refund may not be requested from the provider until the potential fraud issue is resolved.    Initiating provider or supplier specific edits to focus prepayment view on the problem provider or supplier or group of providers or suppliers, if appropriate  ;   Working with the CMS Central Office Division of Benefit Integrity Management Operations (DBIMO) Fraud and Abuse Suspensions and Sanctions (FASS)  Team to suspend payment to the provider or group of  providers;    Referring provider certification issues to the State survey agency through CMS staff;    Referring quality issues involving inpatient hospital services to the RO and QIO; and    Coordinating with the QIO and MAC on interrelated billing problems   The MACs periodically perform a follow -up analysis of the provider(s) or supplier(s) for as long as necessary to determine if further corrective actions are required. In some cases, it may be feasible and timely to perform the follow -up analysis of the p rovider or supplier after the three (3) month time period. The MACs shall continue to monitor the provider(s) or supplier(s) until there is a referral to the UPICs for potential fraud, evidence that the utilization or billing problem is corrected, or data analysis indicating resources would be better utilized elsewhere.   3.7.4 - Tracking Appeals  (Rev. 377, Issued: 05- 27-11, Effective: 06 -28-11, Implementation: 06- 28-11)  This section applies to MACs.  The MACs shall track and evaluate the results of appeals . It is not an efficient use of medical review resources to deny claims that are routinely reversed upon appeal.  When such outcomes are identified, MACs shall take steps to understand why hearing or appeals officers viewed the case differently from them, and discuss appropriate changes in policy, procedure, outreach or review strategies with the regional office.   3.7.5 - Corrective Action Reporting Requirements  (Rev.: 10100; Issued: 05- 08-2020; Effective: 06 -09-2020; Implementation: 06- 09-2020)   A. General   This section applies to MACs.   The CMS will provide information to the MACs regarding CMS Recovery Audit Contractor (RAC), and OIG -identified issues via Technical Direction Letters (TDLs) . The TDLs will be sent to the MACs on a quarterly basis. Each MAC shall report corrective actions by the dates stated in the TDLs.   B. Corrective Action Reporting on CMS and OIG -Identified Issues   The CMS will provide MACs with a list of issues on an Excel spreadsheet template (Corrective Actions Taken on CMS and OIG -Identified Issues). These issues may be uncovered by the RAC, OIG audits, internal CMS analysis, or other means. The MACs shall review the spreadsheet, type precise responses on the template  (see interim and final reportable action statement samples below), and upload the excel file or flat file to the RAC Data Warehouse (RAC DW).   For each of the issues, MACs shall report interim actions, final actions, and action dates (see interim and fin al reportable action statement examples below). The common factor between all reportable actions is quantifiability. The distinguishing factor between the two types of reportable actions is intervention implementation. Interim reportable actions generally indicate in -progress reviews of issues prior to the initiation of final actions. Final reportable actions indicate specific interventions completed to prevent future improper payments.