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Medical Review Overview

Our Medical Review program helps ensure that Medicare Fee-for-Service (FFS) claims are paid correctly and in accordance with Medicare coverage, coding, billing, and payment requirements. Through data analysis, claim review, provider education, and collaboration with CMS, Medical Review activities support program integrity and help reduce improper payments.

CMS uses the Comprehensive Error Rate Testing (CERT) program to measure improper payments in the FFS program and identify opportunities to improve claim payment accuracy.

Data Analysis

Data analysis is an essential component of Medical Review and program integrity activities used to identify actual or potential claim payment errors and potential fraud. Contractors analyze Medicare claims and other relevant data to identify billing patterns, statistical outliers, changes in utilization, and other indicators of potential improper billing or payment. 

Data analysis may be used to:

  • Identify areas of potential error and financial risk to the Medicare program.
  • Identify unusual billing or utilization patterns and statistical outliers.
  • Establish priorities and target areas for medical review.
  • Support the development of appropriate prepayment or post-payment review strategies.
  • Identify trends or patterns that may warrant provider education or other corrective action.
  • Support the identification and verification of potential improper payments or fraud. 

Contractors may use CMS data, claims and payment data, CERT findings, complaints, provider or beneficiary information, fraud alerts, and information from CMS or other government and nongovernment sources to identify potential issues. Potential errors should be verified before administrative action is taken and prioritized based on the level of risk to the Medicare program.

Purpose

Medical Review is an essential component of Medicare program integrity. We use data analysis and medical review to identify potential claim payment errors, review claims and supporting documentation for compliance with Medicare requirements, provide provider education, and take appropriate corrective action.

Medical Review activities may include:

  • Analyzing claims data to identify potential errors and billing trends;
  • Reviewing claims and supporting documentation for compliance with Medicare coverage, coding, billing, and documentation requirements;
  • Providing education to improve provider compliance; and
  • Coordinating with CMS and other program integrity partners when additional action is appropriate.

How Reviews Are Identified

Under Section 1842 of the Social Security Act (42 U.S.C. § 1395u), Medicare Part B is administered through contracts with Medicare Administrative Contractors (MACs).

We use data analysis to identify billing patterns, utilization trends, and potential claim payment errors that may warrant further review. When a potential issue is identified, additional analysis or medical review may be conducted to verify the concern and determine the appropriate action.

Statutory reference: Social Security Act § 1842, 42 U.S.C. § 1395u

Targeted Probe and Educate (TPE)

TPE combines claim review with individualized provider education to improve billing accuracy and reduce claim errors, denials, and appeals. Our TPE process may include up to three rounds of prepayment or post-payment review with education provided throughout the process. Providers demonstrating improvement may be discontinued from review. Providers with continued high denial rates after three rounds are referred to CMS for determination of additional action.

For additional information, visit the TPE page.

Prepayment and Post-Payment Review

We emphasize prepayment medical review as a strategy for identifying and addressing potential claim payment errors before payment is made. Under prepayment review, supporting documentation is evaluated before an initial claim determination and payment. Data analysis may be used to identify services or providers for targeted review, and education may be provided to promote compliance and prevent future errors.

Post-payment review may also be conducted when appropriate. Supporting documentation is evaluated after payment, and the review may result in provider education, claim adjustment, or recoupment, as applicable.

Providers and suppliers are expected to submit claims that comply with applicable Medicare coverage, coding, billing, and documentation requirements.

Learn more:

Additional Documentation Requests (ADRs) and Record Development

When additional information is needed to make coverage, coding, or payment determination, we may issue an ADR for medical records or other supporting documentation. Documentation may be requested from the billing provider or, when appropriate, from a third party involved in the beneficiary's care.

Providers should submit all requested documentation within the timeframe specified in the ADR and follow the submission instructions provided. Our ADR process generally provides a 45-day period for submitting requested documentation. Failure to respond timely or provide sufficient documentation to support the services billed may result in claim denial. 

Before submitting documentation, providers should ensure that:

  • The records correspond to the date of service and services requested.
  • All relevant documentation necessary to support the claim is included.
  • Documentation is legible and properly authenticated in accordance with Medicare signature requirements. For additional information, visit the: Signature Requirements: Guidelines for Authentication of Medicare Services
  • Records are submitted using the method and destination specified in the ADR. 

For provider-specific TPE reviews, we notify providers of the reason for selection, the review process, and the services subject to review. Reviews may be conducted on a prepayment or post-payment basis.

For additional information, visit the ADR page.

How Providers Can Prepare

Providers should ensure documentation supports the medical necessity of services rendered and complies with applicable Medicare coverage, coding, billing, and documentation requirements. Maintaining complete and accurate records helps support claim payment and facilitates the medical review process when records are requested.

Appeals

Providers and suppliers have the right to appeal Medicare claim determinations. If you disagree with a Medical Review determination, you may request a redetermination, the first level of the Medicare appeals process. 

The TPE process does not change existing Medicare appeal rights. We consider appeal decisions that are overturned before a subsequent TPE round is initiated. 

For information on filing an appeal, submission options, forms, and appeal levels, visit the Appeals page. 

If you identify an overpayment, visit the Overpayments page for instructions and forms to report or return the overpayment. Once an overpayment is identified, the excess amount becomes a debt owed to Medicare.

 

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