evekhm/cms_iom_500 huggingface dataset:
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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)
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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.
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 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).
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 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:
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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
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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.
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Examples of interim reportable action statements:    MAC is planning a  50% post -payment review (to be performed between 08/01/2014  08/31/2014) of 200 claims (with dates of service between 01/01/2012  12/31/2012).   MAC performed a 100% pre -payment review for DRG numbers ###  ### on 02/14/2014 (with dates of service betwee n 01/01/2012  12/31/2012).   MAC performed a pre -payment widespread review using a 100 claim probe on 03/26/2014 (with dates of service between 01/01/2012  12/31/2012).   MAC performed a provider -specific pre- payment review on 04/17/2014 (with dates of ser vice between 01/01/2012  12/31/2012).   Due to resource limitations, not yet able to fully research issue (with dates of service between 01/01/2012  12/31/2012).   Examples of final reportable action statements:    MAC held a provider seminar for 500 chiropractors regarding documentation requirements on 11/12/2013.   MAC published an article regarding billing for nebulizer drugs on 02/27/2014 that explained the coverag e policy for nebulizer drugs.   MAC installed an automated edit and validated functionality on 03/19/2014 for codes ###  ###.  o If readily available, please provide edit effectiveness as defined in PIM section 3.7.3.1  Evaluation of Prepayment Edits. <Plea se insert cost savings and number or percentage of claims denied.>    MAC performed a provider - specific review resulting in a provider education activity. <Comparative Billing Report, letter, one -on-one telephone explanation,>on 05/19/2014.   Based on ana lysis, this is not an issue within jurisdiction X.   Interim and final reportable action statement rationales:    In the additional comments section of the TDL template, MACs shall provide brief supplementary rationales for the reported actions. o For example, rationales may state that analysis produced no significant findings due to low volume, claims paid, lower risk and lower priority ranking when compared with other issues.
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 The MACs have the discretion to also utilize the additional comments section to briefly explain pertinent background information regarding the MACs processes for specific issues. The MACs may also utilize the space to communicate suggestions for CMS to consider regarding possible future actions.  The MACs shall use the format (Corrective Actions Taken on CMS and OIG -Identified Issues) located in Exhibit 18, section A for reporting purposes. The MACs shall use the prescribed format, acceptable to the RAC DW. The MACs shall upload the file by the date specified in the TDL. If the due dates fall on a weekend or a federal holiday, the MAC shall upload the file on the closest business day after the weekend or holiday. A TDL may occasionally provide an exception to the submission criteria described in the  PIM and the exception will be stated within the text of the memorandum.   Updates to previous reportable actions   The MACs shall keep CMS informed of any updates or changes to interim or final reportable actions on top issues from past TDL responses. The  format located in Exhibit 18, Section A will included a column titled Updated Responses. The MACs shall enter the following information, in a single cell, for each update:   The New Issue number being updated   The Issue Label   The fiscal year and quarter  that the responses were first provided   The type of response originally provided [Interim or Final]   The type of response being provided in the update [Interim or Final]   The response statement in the format described above   The MACs should leave this se ction blank if they have no updates for the quarter.
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The MACs should leave this se ction blank if they have no updates for the quarter.   C. Overpayment Recovery Reporting   The CMS will provide the MACs with specific claims information from Office of the Inspector General (OIG) audits on a quarterly basis via TDLs. These specific claims  have not been reviewed by the OIG and overpayments have not yet been identified. The MACs have the discretion to review these specific OIG -identified claims. The MACs shall report overpayment recoveries pertaining to the specific OIG -identified claims to the CMS on a quarterly basis. If the MAC does not plan on conducting review or cannot conduct review on the specific OIG -identified claims, the MAC shall indicate that no medical review will be conducted and shall also indicate the reason why no medical review and/or overpayment recovery will be conducted on the particular claims set. The reporting shall include the Medicare contractor number, the OIG audit number (e.g. A - 01-08-00528, OEI -01-04-0060) and the cumulative amount collected on the overpayments resulting from the specific set of OIG -identified claims. The cumulative amount shall include appeals. The CMS will indicate the final reporting date in the reporting document when the recovery process has been completed for a specific set of OIG-identif ied claims. CMS will indicate when the report shall be closed. The MACs have the discretion to report on overpayments that have been referred or are uncollectable at this time resulting from the specific set of OIG -identified claims.
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The MACs shall submi t their response to CMS on or before March 1, June 1, September 1, and December 1. If the due dates fall on a weekend or a federal holiday, the MACs shall submit the report on the closest business day after the weekend or holiday. The MACs shall submit the ir response in Excel via email to the CMS contact indicated in the most recent TDL from CMS which includes the claim information and report number. The MACs shall use the format titled Overpayment Recovery on OIG Claims Format located in Exhibit 18 for r eporting purposes. The MAC has the discretion to readjust the format for use in Excel. The MAC shall complete all fields in the format except for the one optional column. The MACs have the discretion to complete the column titled Overpayments referred or uncollectable (in dollars).    3.8 - Administrative Relief from MR During a Disaster  (Rev. 10365; Issued: 10- 02-20; Effective: 08 -27-20; Implementation: 08 -27-20)  This section applies to MACs and Recovery Auditors. UPICs refer to the PIM chapter 4.   A. General   When a disaster occurs, whether natural or man -made, MACs and Recovery Auditors shall anticipate both an increased demand for emergency and other health care services, and a corresponding disruption to normal health care delivery systems and networks. In disaster situations, MACs should do whatever they can to ensure that all Medicare beneficiaries have access to the emergency or urgent care they need. MACs are encouraged to let providers know (via Web site, responses to provider calls, etc.) that the provider's first responsibility, as in any emergency, is to provide the needed emergency or urgent service or treatment. The MACs should assure providers they will work with providers to ensure that they receive payment for all covered services. The administrative flexibility available to MACs and Recovery Auditors is discussed below. These actions will prevent most inappropriate denials and subsequent appeals.   B. Definition of Disaster
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B. Definition of Disaster   A disaster is defined as any natural or man- made catastrophe (such as hurricane, tornado, earthquake, volcanic eruption, mudslide, snowstorm, tsunami, terrorist attack, bombing, fire, flood, or explosion) which causes damage of sufficient severity and magnitude to partially or completely destroy medical records and associated documentation that could be requested by the MACs and Recovery Auditors in the course of a Medicare audit, interrupt normal mail service (including US Postal delivery, overnight parcel delivery services, etc.), and/or otherwise significantly limit the provider's daily operations.  A disaster may be widespread and impact multiple structures (e.g., a regional flood) or isolated and impact a single site only (e.g., water main failure). The fact that a provider is located in a presidentially declared disast er area under the power of the Stafford Act is not sufficient in itself to justify administrative relief, as not all structures in the disaster area may have been subject to the same amount of damage. Damage must be of sufficient severity and extent to compromise retrieval of medical documentation.  C. Basis for Providing Administrative Relief   In the event of a disaster, MACs and Recovery Auditors shall grant temporary administrative relief to any affected providers for up to 6 months (or longer with good cause). Administrative relief is to be granted to providers on a case-by- case basis in accordance with the following guidelines:   The MACs and Recovery Auditors shall make every effort to be responsive to providers who are victims of the disaster and whose medical documentation may be partially or completely  destroyed.   Providers must maintain and submit verification upon contractor request by the MAC or Recovery Auditor that (1) a disaster has occurred and (2) medical  record loss resulted from this disaste r to the point where administrative relief from medical review requirements is necessary to allow the provider sufficient time to retrieve copies of, or restore damaged, medical  documentation.  Verification of the disaster and the resultant damage should i nclude but is not limited to:
(Medicare Program Integrity Manual)
Verification of the disaster and the resultant damage should i nclude but is not limited to:   (1) Copies of claims filed by the provider with his/her insurance and liability  company; and (2) Copies of police reports filed to report the damage, (3) copies of claims  submitted to FEMA for financial assistance, (4) copies of tax reports filed to report the losses, or (5) photographs of damage. MACs and Recovery Auditors shall not routinely request providers to submit verification of damage or loss of medical record  documentation.  D. Types of Relief   Providers Directly Affected By Disaster   The MACs and Recovery Auditors shall stop sending ADR letters to providers who have been directly affected for at least 60 calendar days. The MACs and Recovery Auditors shall allow up to an additional six months beyond the original due date for the submission of requested records. Requests for extensions beyond this date can be granted with good cause at the discretion of the MAC or Recovery Auditor.  In the case of complete destruction of medical records where no backup records exist, MACs and Recovery Auditors shall accept an attestation that no medical records exist and consider the services covered and correctly coded. In the case of partial destruction, MACs and Recovery Auditors should instruct providers to reconstruct the records as much as possible with whatever original records can be salvaged. Providers should note on the face sheet of the completely or partially reconstructed medical record: "This record was reconstructed because of disaster."   Providers Indirectly Affected By  Disaster   For providers that are indirectly affected by a disaster (e.g., an interruption of mail service caused by a grounding of US commercial air flights), MACs and Recovery Auditors shall take the following actions:  For ADRs, extend the parameter that triggers denial for non- receipt of medical records from 45 calendar days to 90 calendar days. ADRs shall reflect that the response is due in 90 calendar days rather than 45 calendar days. This action will prevent most inappropriate denials and unnecessary increases in appeals workload.