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Medicare Improper Payment Review

Overview of Improper Payment Review

CMS considers any payment to the wrong provider, for the wrong services or in the wrong amount an improper payment. This includes overpayments and underpayments. These improper payments are most often because statutory coverage requests were not met, medically necessity requirements were not met, the claim was improperly coded or there was not sufficient documentation submitted with the claim. Improper payment review is the evaluation of claims to determine whether the items/services are covered, correctly coded and medically necessary. CMS has developed various payment review entities (Overview of Improper Payment Reviews Conducted by Medicare & Medicaid Review Contractors) to identify improper payments including:

• Medical Review Programs (MR)
• Recovery Auditor Contractors (RAC)
• Comprehensive Error Rate Testing (CERT) Contractors

To avoid or prepare your practice for medical review or audit, check to see if your practice has these common causes of improper payments.

What can you do to prepare your practice?

Physicians can take steps prepare your practice and yourself for medical review or audit. Physicians can look to see what improper payments have been found by these programs by checking OIG reports, permanent RAC findings (can be found on each RACs website), and CERT reports. Check your claims submission to see if there are any improper payments, keep track of denied claims and look for patterns to prepare for a medical record review or audit. Practices can also conduct internal assessment to identify if you are in compliance with Medicare rules and identify any corrective actions to promote compliance. If physicians do find improper payments through an internal review, they are urged to report the error to CMS. Practices can also make sure that their RAC has the precise address and contact person they should use when sending Medical Request letters by calling the RAC or checking their website. Also, review the following common causes of improper payments try and avoid common issues:

• Physician orders missing
• Illegible/missing signatures
• National policy or local policy requirements not met
• The medical record does not support medical necessity

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