What is Medical Review?

The Centers for Medicare and Medicaid Services (CMS) is required by the Social Security Act to ensure payment is made only for those services that are reasonable and necessary in order to protect the integrity of the Medicare Trust fund.

To accomplish this, CMS contracts with a Fiscal Intermediary (FI) such as ABCBS to perform Medical Review. Thus Medical Review is defined as a review of claims to identify and verify inappropriate billing, develop interventions to correct problems and follow up on the effectiveness of previous corrective actions. It is a key component of the Medicare Integrity Program.

Our goal is to pay claims correctly the first time thereby reducing the paid claim error rate. We utilize national and local data to identify the problems that pose the greatest threat to the Medicare Program and we are mandated to educate providers on appropriate billing practices.

We are planning a great deal of education this fiscal year. It will include Newsletter articles, letters, workshops, meetings and web based training so we encourage you to become familiar with this website and watch for changes, updates and notices.

As always, we encourage your comments and feedback so let us know how we can help to better meet your needs.