• rss
  • facebook
  • twitter
  • linkedin

Medicare Improper Payment Review

Medical Review (MR) Programs at MACs

The goal of the medical review program is to reduce payment error by identifying and addressing billing errors concerning coverage and coding made by providers. Claims selections are targeted to claims that are most likely to contain an improper payment. Medicare Administrative Contractors (MACs formerly called fiscal intermediaries and carriers) review CERT data, RAC vulnerabilities and OIG/GAO reports. Contractors also publish local medical review policy (Local Coverage Determination LCD) to provide guidance to the public and medical community about when items and services will be eligible for payment under Medicare. Medicare Learning Network (MLNs) educational articles are also published as they related to the medical review process.

Medical Review Process

The MAC requests medical records via paper letter. Reviews are conducted by clinicians and certified coders. Prepay claims that are found to be improper, will be denied and no payment will be issued. If a postpay claim is found to be improper, overpayment is recouped and underpayment is paid back. Providers can file appeal at MACs.

Some MACs are planning to do simultaneous review of all Part A and Part B claims related to inpatient care episodes. They intend to use A/B cross-claim analysis to better understand and prevent errors. Appropriate claim payments for many services, including inpatient hospital services, require physicians and facilities to ensure proper documentation of medical necessity for the hospital care and related services. Physicians and hospitals must understand that both outpatient and inpatient records should each be able to stand alone to demonstrate medical necessity for related services.

Additional Information & Resources
A/B MAC Jurisdictions:

DME MAC Jurisdictions:

Earn CME Credits

Earn CME Credits through attending live meetings, working online, or watching course recordings on your own schedule.

MKSAP 16 Holiday Special: Save 10%

MKSAP 16 Holiday Special:  Save 10%

Use MKSAP 16® to earn MOC points, prepare for ABIM exams and assess your clinical knowledge. For a limited time save 10% when you use priority code MKPROMO! Order now.

Maintenance of Certification:

What if I Still Don't Know Where to Start?

Maintenance of Certification: What if I Still Don't Know Where to Start?

Because the rules are complex and may apply differently depending on when you last certified, ACP has developed a MOC Navigator. This FREE tool can help you understand the impact of MOC, review requirements, guide you in selecting ways to meet the requirements, show you how to enroll, and more. Start navigating now.