(Medicare Program Integrity Manual)

If a provider/supplier continues to have a high error rate at the conclusion of three rounds of TPE, the MAC shall refer to  CMS for further action. Referrals shall include details regarding the reason the provider/supplier was selected for TPE review, TPE review results, results of appealed denials (to the extent available at the time of referral), any education provided (or offered and refused), and any other relevant information that may be helpful in determining appropriate next steps.  The MAC shall refer suspected fraudulent providers to the UPIC at any time during the TPE process.   F. Next Steps   Once the MAC refers a pro vider/supplier to CMS, details are reviewed to determine if additional action must be taken by the MAC. Additional actions that may be required include, but are not limited to, additional rounds of TPE review, 100 percent prepayment review, extrapolation, referral to a Recovery Auditor, and/or referral for revocation. If CMS directs the MAC to conduct an additional round of TPE review, the MAC shall send the provider/supplier a notification letter indicating that an additional round of review is required.  These reviews shall be of claims with dates of service at least 45 days after the prior rounds post probe education and after the provider/supplier has received the aforementioned notification letter.   3.3  Policies and Guidelines Applied During Review  (Rev. 10365; Issued: 10- 02-20; Effective: 08 -27-20; Implementation: 08 -27-20)  This section applies to MACs, CERT, Recovery Auditors, Supplemental Medical Review Contractors (SMRCs) and UPICs, as indicated.   A. Statutes, Regulations, the CMS Rulings, National Coverage Determinations, Coverage Provisions in Interpretive Medicare Manuals, and Local Coverage Determinations   The primary authority for all coverage provisions and subsequent policies is the Social Security Act. In general, MACs, CERT, Recovery Audit ors, SMRCs, and UPICs shall apply the provisions of the Act according to the following hierarchy of documents in effect at the time the item(s) or service(s) was provided to make medical review decisions:   Social Security Act  Code of  Federal Regulations C MS Rulings  National Coverage Determination (NCDs)  Coverage provisions in Interpretive Manuals or Internet Only Manuals (IOM) which includes Medical Review Guidance in the Medicare Program Integrity Manual  CMS coding policies  Technical Direction Letters (TDLs)* The relevant MACs Local  Coverage Determination (LCDs) The relevant MACs local  articles  AHA Coding Clinics.  *TDLs that contain MR guidance may provide an exception to this hierarchy.   B. Coding  Guidelines   The MACs, CERT,  Recovery Auditors, and UPICs shall apply coding guidelines to services selected for review. All contractors shall determine that an item/service is correctly coded when it meets all the coding guidelines listed in the Current Procedural Terminology- 4 (CPT ) book, International Classification of Diseases Guidelines (ICD), CMS HCPCS or ICD policy or guideline requirements, LCDs, or MAC articles.  C. Internal Medical Review Guidelines   The MAC, CERT, Recovery Auditor, and UPIC staffs have the discretion to develop detailed written review guidelines to guide staff during claim reviews. Internal MR guidelines shall specify the information to be reviewed by reviewers and the appropriate resulting determination. Recovery Auditors are required to develop written review  guidelines in accordance with their SOW. The MACs, CERT, Recovery Auditors, and UPICs shall make their internal MR guidelines available to their staff, as needed. Internal MR Guidelines shall not create or change the CMS policy.  3.3.1 - Types of Review: Medical Record Review, Non -Medical Record Review, and Automated Review  (Rev. 10365; Issued: 10-02- 20; Effective: 08 -27-20; Implementation: 08-27-20)  This section applies to MACs, CERT, SMRC, and UPICs, as indicated.  A. General   Most o f the claim review activities completed for the purpose of identifying inappropriate billing and avoiding improper payments are divided into three distinct types: Medical Record Review, Non- Medical Record Review, and Automated Review.   The chart below indicates which contractors perform which types of review:  Prepayment  Postpayment   Medical  Non-  Medical  Non- Contractor  Record  Medical  Automated  Record  Medical  Type  Review  Record  Reviews  Review  Record    Review    review  MACs  Yes Yes Yes Yes Yes CERT  No No No Yes No RACs  No No No Yes No SMRC  No No No Yes Yes UPIC  Yes No No Yes Yes   3.3.1.1 - Medical Record Review  (Rev. 11529; Issued: 07-28-2022; Effective: 08- 30-2022; Implementation: 08-30-2022)  This section applies to MACs, CERT, RACs, Supplemental Medical Review Contractor(s) and UPICs, as indicated.  A. Definition   Medical record review involves requesting, receiving, and reviewing medical documentation associated with a claim.   Medical record review, for the purpose of determining medica l necessity, requires a licensed medical professional to use clinical review judgment to evaluate medical record documentation.  B. Clinical Review Judgment   Clinical review judgment involves two steps:   1. The synthesis of all submitted medical record information (e.g. progress notes, diagnostic findings, medications, nursing notes, etc.) to create a longitudinal clinical picture of the patient; and  2. The application of this clinical picture to the review criteria is to make a reviewer determination on whether the clinical requirements in the relevant policy have been met. MAC, CERT, RAC, and UPIC clinical review staff shall use clinical review judgment when making medical record review determinations about a  claim.   Clinical review judg ment does not replace poor or inadequate medical records. Clinical review judgment by definition is not a process that MACs, CERT, RACs and UPICs can use to override, supersede or disregard a policy requirement. Policies include laws, regulations, the CMS  rulings, manual instructions, MAC policy articles attached to an LCD or listed in the Medicare Coverage Database, national coverage decisions, and local coverage determinations.  C. Credentials of Reviewers   The MACs, MRAC, and CERT shall ensure that medical  record reviews for the purpose of making coverage determinations are performed by licensed nurses (RNs), therapists or physicians. Current LPNs may be grandfathered in and can continue to perform medical record review. The MACs, MRAC, and CERT shall not hire any new LPNs to perform medical record review. UPICs, RACs and the SMRC shall ensure that the credentials of their reviewers are consistent with the requirements in their respective SOWs.   During a medical record review, nurse and physician reviewers m ay call upon other health care professionals (e.g., dieticians or physician specialists) for advice. The  MACs, MRAC, and CERT, shall ensure that services reviewed by other licensed health care professionals are within their scope of practice and that their  MR strategy supports the need for their specialized expertise in the adjudication of particular claim type (i.e., speech therapy claim, physical therapy). RACs and the SMRC shall follow guidance related to calling upon other healthcare professionals as outlined in their respective SOWs.   RACs shall ensure that a licensed medical professional will perform medical record reviews for the purpose of determining medical necessity, using their clinical review judgment to evaluate medical record documentation. Ce rtified coders will perform coding determinations. CERT and MACs are encouraged to make coding determinations by using certified coders. UPICs have the discretion to make coding determinations using certified coders.   D. Credential  Files   The MACs, MRAC, CERT, RACs, and UPICs shall maintain a credentials file for each reviewer (including consultants, contract staff, subcontractors, and temporary staff) who performs medical record reviews. The credentials file shall contain at least a copy of the reviewers  active professional license.   E. Quality Improvement (QI) Process   The MACs, CERT, RACs, and SMRCs shall establish a Quality Improvement (QI) process that verifies the accuracy of MR decisions made by licensed health care professionals. The MACs, CERT, RACs, and SMRCs shall attend the annual medical review training conference as directed by the CMS and/or their SOW. The MACs, CERT, RACs, and SMRCs shall include inter -rater reliability assessments in their QI process and shall report these results as directed by CMS.   F. Advanced Beneficiary Notice (ABN)   The MACs, CERT, RACs, UPICs, and SMRCs shall request as part of the ADR, during a medical record review, a copy of any mandatory ABNs, as defined in Pub. 100-  04, Medicare Claims Processing Manual Chapter 30 sect ion 50.3.1. If the claim is determined not to be reasonable and necessary, the contractor will perform a face validity assessment of the ABN in accordance with the instructions stated in Pub. 100- 04 Medicare Claims Processing Manual chapter 30 section 50.6.3.  The Face Validity assessments do not include contacting beneficiaries or providers to ensure the accuracy or authenticity of the information. Face Validity assessments will assist in ensuring that liability is assigned in accordance with the Limitatio ns of Liability Provisions of section 1879 of the Social Security Act.  G. MAC Funding Issues   The MAC -medical record review work performed by medical review staff for purposes other than MR (e.g., appeals) shall be charged, for expenditure reporting purposes, to the area requiring medical review services.   All medical record review work performed by MACs shall:    Involve activities defined under the Medicare Integrity Program (MIP) at Section 1893(b)(1) of the  Act;  Be articulated in its medical review strategy;  and  Be designed in such a way as to reduce its Comprehensive Error Rate Testing (CERT) error rate or prevent the contractors error rate from  increasing.   The MACs shall be mindful that edits suspending a claim for medical review to check for issues other than inappropriate billing (i.e. completeness of claims, conditions of participation, quality of care) are not medical review edits as defined under Section 1893(b)(1) of the Act and cannot be funded by MIP. Therefore, edits resulting in work other than that defined in Section1893 (b) (1) shall be charged to the appropriate Program Management activity cost center. Activities associated with claims processing edits shall not be charged to MIP.  H. Review Timeliness Requirements   Prepayment Review Requirements for MACs   When a MAC receives requested documentation for prepayment review within 45 calendar days of the date of the ADR, the MAC shall do the following within 30 calendar days of receiving the requested documentation: 1) make and doc ument the review determination and 2) enter the decision into the Fiscal Intermediary Shared System (FISS), Multi -Carrier System (MCS), or the VIPS Medicare System (VMS). The 30 calendar day timeframe applies to prepayment non- medical record reviews and prepayment medical record reviews. The 30 calendar day timeframe does not apply to prepayment reviews of Third Party Liability claims. The MACs shall make and enter a review determination for Third Party Liability claims within 60 calendar days.  Counting the 30 Calendar Day Timeframe   The MACs and RACs shall count day one as the date each new medical record is received in the mailroom. The MACs and RACs shall give each new medical record received an independent 30 day review time period.  Prepayment Review Requirements for UPICs   When a UPIC receives all documentation requested for prepayment review within 45 calendar days of the date of the ADR, the UPIC shall make and document the review determination and notify the MAC of its determination within 60 calendar days of receiving all requested documentation. Medical review for the purpose of fraud, waste, or abuse requires 60 days to allow for the integration of information from the investigative process. This information may be a result of recent/concurrent investigative actions such as beneficiary/provider/supplier interviews, site visits and/or receipt of additional internal/external information.   Post-payment Review Requirements for MACs  The MAC shall make a review determination, and mail the review results notification letter to the provider within 60 calendar days of receiving the requested documentation.  For claims associated with any referrals to the UPIC for program integrity investigation, MACs shall stop counting the 60-day time period on the date the referral is made. The 60-day time period will be restarted on the date the MAC received requested input from the UPIC or is notified by the UPIC that the referral has been declined.   For claims sent to MR for reopening by the contractor appeals de partment, in accordance with Pub. 100-04, chapter 34, 10.3, begin counting the 60 days from the time the medical records are received in the MR department.   Post-payment Review Requirements for RACs  When a RAC receives requested documentation for review within 45 calendar days of the date of the ADR, the RAC shall do the following within 30 calendar days of receiving the requested documentation: 1) make and document the review determination, and 2) communicate the results to the provider.  State Laws that  Affect Prepayment Review Timeliness Requirements