(Medicare Program Integrity Manual)

 Frequency to Time - permits contractors to screen for a certain number of  services provided within a given time  period.   Diagnosis to Procedure - permits contractors to screen for services submitted with a specific diagnosis. For example, the need for a vitamin B12 injection is related to pernicious anemia, absent of the stomach, or distal ileum. Contractors must be able to establish edits where specific diagnosis/procedure relationships are considered in order to qualify the claim for  payment.    Procedure to Specialt y Code or TOB - permits contractors to screen  services provided by a certain specialty or  TOB.    Procedure to Place of Service-  permits selective screening of claims where the service was provided in a certain setting such as a comprehensive outpatient rehab ilitation  facility.   Additional MAC system comparisons shall include, but are not limited to the following:    Diagnoses alone or in combination with related factors.    Revenue linked to the health care common procedure coding system  (HCPCS).    Charges related  to utilization, especially when the service or procedure has  an established dollar or number  limit.    Length of stay or number of visits, especially when the service or  procedure violates time or number  limits.    Specific providers alone or in combination w ith other  parameters.   The MR edits are coded system logic that either automatically pays all or part of a claim, automatically denies all or part of a claim, or suspends all or part of a claim so that a trained clinician or claims analyst can review the claim and associated documentation (including documentation requested after the claim is submitted) in order to make determinations about coverage and payment under Section 1862(a) (1) (A) of the Act.   Namely, the claim is for a service or device that is medically reasonable and necessary to diagnose or treat an injury or improve the functioning of a malformed body member. All non-automated review work resulting from MR edits shall:    Involve activities defined under the MIP at 1893(b)(1) of the  Act;   Be articulated in the MACs medical review  strategy;    Be designed in such a way as to reduce the MACs CERT error rate or prevent the MACs CERT error rate from increasing,  or;  Prevent improper payments identified by the RACs.  3.2.1  Setting Priorities and Targeting Reviews  (Rev. 399, Issued: 11- 04-11, Effective: 12 -05-11, Implementation: 12- 05-11)  This section applies to MACs and Recovery Auditors, as indicated. Recovery Auditors perform targeted reviews consistent with their statements of work (SOWs).   The MACs have the authority to review any claim at any time, however, the claims volume of the M edicare Program doesnt allow for review of every claim. The MACs shall target their efforts at error prevention to those services and items that pose the greatest financial risk to the Medicare program and that represent the best investment of resources. This requires establishing a priority setting process to assure MR focuses on areas with the greatest potential for improper payment.   The MACs shall develop a problem -focused, outcome -based MR strategy and Strategy Analysis Report (SAR) that defines what risks to the Medicare trust fund the MACs MR programs will address and the interventions that will be implemented during the fiscal/option year as addressed in PIM chapter 7.   The MACs shall focus their edits where the services billed have significant pot ential to be non-covered or incorrectly coded. Medical review staff may decide to focus review on problem areas that demonstrate significant risk to the Medicare program as a result of inappropriate billing or improper payments. The MACs shall have in plac e a program of systematic and ongoing analysis of claims and data from Recovery Auditors and CERT, among other sources, in order to focus intervention efforts on the most significant errors.   The MACs shall initiate a targeted provider -specific prepayment review only when there is the likelihood of sustained or high level of payment error. MACs are encouraged to initiate targeted service- specific prepayment review to prevent improper payments f or services identified by CERT or Recovery Auditors as problem areas, as well as, problem areas identified by their own data analysis.   The MACs have the discretion to select target areas because of:    High volume of services;   High cost;   Dramatic change in frequency of use;   High risk problem -prone areas; and/or,   Recovery Auditor, CERT, Office of Inspector General (OIG) or Government Accounting Office (GAO) data demonstrating vulnerability. Probe reviews are not required when targeted areas are based on data from these entities.   In an effort to identify the claims most likely to contain improper billing, MACs are encouraged to use prepayment and postpayment screening tools or natural language coding software. MACs shall not deny a payment for a service simply because the claim fails a single screening tool criterion. Instead, the reviewer shall make an individual determination on each claim. MACs have the discretion to post the screening tools in use to their Web site or otherwise disclose to the provide r community. Recovery Auditors shall use screening tools and disclose their use to the provider community consistent with the requirements in their statements of work (SOWs).   MACs and Recovery Auditors shall NOT target a provider for review solely based on the providers preferred method of maintaining or submitting documentation.  For example, a MAC or Recovery Auditor shall NOT choose a provider for review based only on the fact that the provider uses an electronic health record or responds to documentat ion requests using the Electronic Submission of Medical Documentation (esMD) mechanism.  (More information about esMD can be found in Section (3.2.3.5)   3.2.2 - Provider Notice  (Rev. 10365; Issued: 10- 02-20; Effective: 08 -27-20; Implementation: 08 -27-20)  This section applies to MACs, RACs, UPICs, and SMRC as indicated.  Because the CERT contractors select claims on a random basis, they are not required to notify providers of their intention to begin a review.  Providers may submit unsolicited documentation to the MAC when submitting a claim. Providers are to list the PWK 02 Report Transmission Code (PWK (paperwork) modifier) on the claim when submitting this documentation. MACs should inform the providers that they are NOT required to submit unsolicited documentation (and the corresponding PWK modifier) and that the absence or presence of PWK modifier does not mean that their claim will be reviewed. MACs should, at their discretion, consider posting to their webs ite or sending letters to providers informing them of what additional documentation is needed to make a determination on the claim.  A. Notice of Provider- Specific  Review   When MAC data analysis indicates that a provider -specific potential error exists that cannot be confirmed without requesting and reviewing documentation associated with the claim, the MAC shall review a sample of representative claims. Before deploying significant medical review resources to examine claims identified as potential problems through data analysis, MACs shall take the interim step of selecting a small "probe" sample of generally 20- 40 potential problem claims (prepayment or postpayment) to validate the hypothesis that such claims are being billed in error. This ensures that medic al review activities are targeted at identified problem areas.  The MACs shall ensure that such a sample is large enough to provide confidence in the result, but small enough to limit administrative burden. The CMS encourages the MACs to conduct error validation reviews on a prepayment basis in order to help prevent improper payments.  MACs shall select providers for error validation reviews in the following instances, at a minimum:    The MAC has identified questionable billing practices (e.g., non-covered, incorrectly coded or incorrectly billed services) through data analysis;    The MAC receives alerts from other MACs, Quality Improvement Organizations (QIOs), CERT, RACs, OIG/GAO, or internal/external components that warrant review;    The MAC receives complai nts; or,   The MAC validates the items bulleted in  3.2.1.  Provider -specific error validation reviews are undertaken when one or a relatively small number of providers seem to be experiencing similar/recurrent problems with billing. The MACs shall document their reasons for selecting the provider for the error validation review. In all cases, they shall clearly document the issues noted and cite the applicable law, published national coverage determination, or local coverage determination.  For provider-specific problems, the MAC shall notify providers in writing that a probe sample review is being conducted. MACs shall consider sending letters to providers informing them of what additional documentation is needed to make a determination on the claim. MACs have the discretion to use a letter similar to the letters in Exhibit 7 of the PIM when notifying providers of the probe review and requesting documentation. MACs have the discretion to advise providers of the probe sample at the same time t hat medical documentation or other documentation is requested.  Generally, MACs shall subject a provider to no more than one probe review at any time; however, MACs have the discretion to conduct multiple probes for very large billers as long as they will not constitute undue administrative burden.  MACs   The MACs shall notify selected providers prior to beginning a provider- specific review by sending an individual written notice. MACs shall indicate whether the review will occur on a prepayment or postpayment basis. This notification may be issued via certified letter with return receipt requested. MACs shall notify providers of the specific reason for selection. If the basis for selection is comparative data, MACs shall provide the data on how the provider varies significantly from other providers in the same specialty, jurisdiction, or locality. Graphic presentations help to communicate the perceived problem more clearly.  RACs   The RACs are required to post a description of all approved new issues to the RACs Web site before correspondence is sent to the provider. After posting, the RAC should issue an additional documentation request (ADR) to the provider, if warranted.  Unified Program Integrity Contractor (UPIC)   The UPICs shall notify selected providers prior to beginning a provider- specific review by sending an individual written notice. UPICs shall indicate whether the review will occur on a prepayment or postpayment basis. UPICs shall maintain a copy of the letter and the date it was mailed. This notification shall be mailed the same day that the edit request is forwarded to the MAC. Refer to Exhibit 45 for the letter to be sent.  B. Notice of Service -Specific Review   This section applies to MACs, RACs and SMRC as indicated.  Service- specific reviews ar e undertaken when the same or similar problematic process is noted to be widespread and affecting one type of service (e.g., providing tube feedings to home health beneficiaries across three (3) states).   MACs   Web site postings  The MACs shall provide notification prior to beginning a service- specific review by posting a review description on their Web site. MACs should, at their discretion, state what additional documentation is needed from providers to make a claim determination on their Web site. MACs shall keep the Web site current by posting active reviews.  MACs should, at their discretion, create an archive for old review topics that are no longer under active review. Active review is defined as the time period during which ADRs are sent, determinations are made and findings are communicated to the providers. MACs should categorize the active review topics by provider type.  Individual written notices   MACs have the discretion to also notify providers about a service- specific review by sending individual notices to the affected providers. MACs have the discretion to issue the notice separately or include it in the ADR. MACs should, at their discretion, state what additional documentation is needed from providers to make a claim determination in the written notices.   RACs   Before beginning widespread service-specific reviews, RACs shall notify the provider community that the RAC intends to initiate review of certain items/services through a posting on the RAC Web site describing the item/servi ce that will be reviewed.   Additionally, for medical record reviews, the RACs shall send ADRs to providers that clearly articulate the items or services under review and indicate the appropriate documentation to be submitted.  Unified Program Integrity  Contractors (UPICs)   The UPICs shall provide notification prior to beginning a service- specific review by sending individual written notices to the affected providers. This notification shall be mailed the same day that the edit request is forwarded to the MAC. The UPICs shall maintain a copy of the letter and the date it was mailed. Refer to Exhibit 45 for the letter to be sent.  SMRC   The SMRC shall operate/maintain a public Web site that displays what types of issues are under review. For each area, the S MRC shall include a link to the relevant OIG/GAO or other reports available. In addition to the Web site, the SMRC shall notify providers about a service -specific review by sending an ADR. The SMRC shall state what additional documentation is needed from p roviders to make a claim determination in the ADR.   3.2.2.1 - Maintaining Provider Information  (Rev. 10365; Issued: 10- 02-20; Effective: 08 -27-20; Implementation: 08 -27-20)  The term Medicare beneficiary identifier (Mbi) is a general term describing a bene ficiary's Medicare identification number. For purposes of this manual, Medicare beneficiary identifier references both the Health Insurance Claim Number (HICN) and the Medicare Beneficiary Identifier (MBI) during the new Medicare card transition period and after for certain business areas that will continue to use the HICN as part of their processes.