MR Overview

Our primary mission is to reduce provider billing errors by identifying patterns of inappropriate billing, reviewing claims, and educating providers on medical review claim determination findings. Our primary goal is to pay claims correctly the first time.

We utilize multiple data sources to identify patterns of inappropriate billing.  This includes both data of your billed claims and errors identified by other CMS contractors  (link Other Review Entities).

Once you are identified for a medical review we will notify you. Notification is completed one of two ways:

  • Provider specific Reviews: A review only completed on your facility on a specific service identified.
    • Notice is provided by individual provider letter.
  • Service reviews: Review includes you and other facilities on the same service that was identified as potentially in error.
    • Notice is provided by website article

Our plan and philosophy for education is to educate early and often. The ultimate goal of education is to reduce any claim errors identified during your review.  We may complete this education in multiple methods and frequency. 

The following CMS website page provides more detail on the MR program overview:

https://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/Medicare-FFS-Compliance-Programs/Medical-Review/This link takes you to an external website.


 

Last Updated Apr 21, 2017