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Medicare Improper Payment Review - Medical Review (MR) Programsat 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