Resumption of Postpayment Medical Reviews
As recently published in MACs Resume Medical Review on a Postpayment Basis, Medicare Administrative Contractors (MACs) have resumed fee-for-service medical review activities to protect the Medicare Trust Fund against inappropriate payments. Beginning on or after August 17, 2020, the MACs resumed with postpayment reviews of items and services provided before March 1, 2020.
You may receive an additional documentation request (ADR) requesting medical record documentation associated with a claim selected for a service-specific postpayment review. For more information about services under review and how to respond to an ADR, you may refer to the Receiving and Responding to a Palmetto GBA Additional Documentation Request (ADR) for Postpayment Review and Active Service Specific Postpayment Medical Reviews articles.
Medical review is the collection of information and clinical review of medical records by Palmetto GBA to ensure that payment is made only for services that meet all Medicare coverage, coding and medical necessity requirements. Medical review activities are directed toward areas where data analyses indicate questionable billing patterns.
The goal of the medical review program is to reduce payment errors by identifying and addressing billing errors made by providers concerning coverage and coding. To achieve the goal of the medical review program, Palmetto GBA:
- Proactively identifies patterns of potential billing errors concerning Medicare coverage and coding made by providers through data analysis and evaluation of other information (e.g., complaints);
- Reviews data analysis reports;
- Takes action to prevent and/or address the identified error;
- Publishes local medical review policies via Local Coverage Determinations (LCDs) to provide guidance to the public and medical community about when items and services will be eligible for payment under the Medicare statute.
- CMS Publication 100-08, Medicare Program Integrity Manual, Chapter 3 (PDF, 606 KB)
- CMS Medical Review and Education web page
- Education On Demand