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Medical Review

Noridian Medical Review staff conducts medical record reviews according to the CMS guidelines found in the CMS Internet Only Manual (IOM), Publication 100-08, Medicare Program Integrity Manual, Chapter 3 This link takes you to an external website.. Noridian's goal is to reduce the contractor's claim payment error rate by identifying patterns of inappropriate billing through data analysis, performing medical review of claims and developing local policies to address program vulnerabilities. Reviews are based either on CMS requirements or data analysis findings. MR reviews specific data findings, trend analysis reports, edit evaluation reports, national comparison reports, over utilization reports and Comprehensive Error Rate Testing (CERT) reports. This information is evaluated and a determination is made of the type of reviews to be performed.

Data analysis findings in conjunction with the data source reasons are reviewed and prioritized accordingly, assisting in determination of the appropriate type of review.

Review Brief Description
Service Specific 

In accordance with CMS Progressive Corrective Action (PCA) Plan, Noridian performs prepayment reviews which encompass service specific reviews for multiple providers regarding a particular service such as HCPC codes or CPT codes.

Cross Recovery

When Medical Review performs reviews that result in long-standing high error rates, the MAC may request CMS approval to deny other related claims submitted before or after the claim in question.

Automated Prepayment 

When prepayment review is automated, decisions are made at the system level, using available electronic or claim system information, without the intervention of Noridian personnel. Reviews may be automated with clear policies such as Local Coverage Determinations (LCD) or National Coverage Determinations (NCD).

Routine Prepayment 

Routine review requires hands-on review of the claim and/or claims history file by Noridian personnel using the Medicare online claim system. The review is completed without review of provider medical records.

Complex 

Complex medical review involves the evaluation of the provider's medical records and the application of clinical judgment by a licensed medical professional. Medical records include any medical documentation, other than what is included on the face of the claim that supports the billed service. Complex review is completed as either a prepayment review or a postpayment review.

  • Prepayment Review: Claim review, reasonable and necessary review, and/or coding review, which is made before initial claim payment
  • Postpayment Review: Claim review, reasonable and necessary review, and/or coding review that is performed after claim payment. Postpayment determination either affirms payment of a claim (in full or in part), or denies payment and assesses an overpayment. May result in no change to initial determination or may result in a revised determination

Non-Complex

Non-complex reviews occur when the MAC, CERT, Recovery Auditor, or ZPIC makes a claim determination without clinical review of medical documentation submitted by the provider.

Probe  When Noridian identifies a provider or service as being at risk, the potential error is validated with a prepayment probe (error validation) review. Conducting a probe review ensures that medical review activities are targeted at identified problem areas. Probe reviews are designed to obtain a sample large enough to provide confidence in the result, but small enough to limit administrative burden.
Targeted  Targeted reviews are initiated based on error validation findings and the identification that additional review and education will assist in the correction of provider behavior and prevent future inappropriate billing.

 

Benefits of MR

MR initiatives are designed to ensure that Medicare claims are paid correctly. MR offers many benefits to providers while helping to maintain the integrity of the Medicare Program.

  • Reduced Medicare claims payment error rate – The MR program identifies and addresses billing errors concerning coverage and coding by providers, thus reducing the overall claims payment error rate
  • Decreased denials – Knowledge of the appropriate claim guidelines may result in a reduction in filing errors and an increase in timely payments
  • Increaseeducational opportunities – Medicare provides education on claims that are denied through MR. Contractors also issue articles and other informational materials. The educational processes provided by Medicare help providers know what to expect when a claim is submitted to Medicare for payment

Provider Rights During a Medical Review

A provider has the right, following MR, to be educated on how to bill correctly and to have questions answered in a timely manner. The provider also has the right to appeal determinations, as long as the appeals are filed in accordance with regulations governing that process.

Resources

Last Updated Feb 10, 2017

CPT and ADA End User License Agreement for Providers

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Last Updated Jul 31, 2015