Simply put, this is how Medical Review is conducted! The process and concepts are available online in Chapter 3 of the Program Integrity Manual.

The first step is identification of a potential problem through data analysis.

The second step is verification or validation that a problem exists. To accomplish this, the FI or Carrier performs a probe review on either a prepay or postpay basis, and requests supporting documentation. (See MR web page for more information on the Probe Process).

The third step is Intervention. Medical Review analyzes the probe results and establishes a Provider Error Rate which guides the decisions for follow up, along with other factors such as the total dollar value of the problem and the past history of the provider. The nature of the problem is categorized as minor, moderate or major and the level of concern drives the Interventions.

If the probe review was done on a post pay basis, the overpayment will be collected or offset by Provider Audit and Reimbursement.

In all cases, communication and provider feedback are central issues. Communication will include:

Education is a key factor to correction and may be extended through Newsletter articles, web site postings, web based training modules, letters, phone calls, workshops or face to face meetings.

The next step is Monitoring which may be accomplished through a follow up probe review to ensure continued compliance or for a more egregious problem, a

Preapay targeted medical review (audit) may be put in place.

Problem closure occurs when data analysis or probe results indicate the problem is resolved.

Effectiveness is the final step. Data analysis is an ongoing event, utilized in part to assure corrective action is maintained and not merely shifted to another Bill Type or CPT. In the event of a recalcitrant provider, a referral may be made to the OIG (Office of Inspector General) via one of the Program Safeguard Contractors for investigation of potential fraud.