• 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:

Where We Stand

From the ACA to Medicare reform, ACP is advocating for internists and their patients on issues we care about.

Learn more

Earn CME Credits

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

Annals Virtual Patients Series 1-4 Available

Annals Virtual Patient series 1-4 available

Annals Virtual Patients is a unique online patient simulator that helps you learn while you earn CME Credit and MOC Points.
Start your journey now.

 

ACP keeps you on target to earn MOC Points

ACP keeps you on target to earn MOC Points

December 2015 is the deadline for most internists participating in ABIM MOC to earn some MOC points. Review our stimulating and rewarding options.