What It Is
Medical Review PCA is a concept designed by the Centers for Medicare & Medicaid Services (CMS) for Medicare contractors to use when deploying resources and tools to conduct medical re- views. PCA ensures that medical review activities are targeted at identified problem areas and that corrective actions imposed are appropriate for the severity of the infraction of Medicare rules and regulations. There are four types of corrective actions that may result from medical review evaluations: education, policy development, prepayment review, and postpayment review.
How It Works
The decision to conduct medical review is driven by data analysis. Data analysis is the starting point for contractors to determine unusual or unexpected billing patterns that might suggest improper billing or payment. The data analysis may be general surveillance, or may be specific in response to complaints or reports from various agencies.
Validating the hypothesis of the data analysis is the next step. Before assigning significant resources to examine claims identified as potential problems, probe reviews are conducted. A probe review generally does not exceed 20-40 claims per physician for physician-specific problems, and does not exceed 100 claims distributed among the identified physician community for general, widespread problems. All physicians subject to a probe review are notified in writing that a probe review is being conducted, and are also notified in writing of review results. Physicians or facilities are asked to provide any and all medical documentation applicable to the claims in question.
What It Accomplishes
Once a probe review validates that an error exists, the contractors classify the severity of the error. Errors are classified as minor, moderate, or major. Physician-specific error rate (number of claims paid in error), dollar amounts improperly paid, and past billing history are examples of items used to determine classification level.
If a minor problem is detected, the Medicare contractor will educate the physician on appropriate billing procedures, will collect the money on claims paid in error, and will conduct further analysis at a later date to ensure the problem was corrected.
If a moderate problem is detected, the contractor will educate the physician on appropriate billing procedures, will collect the money on claims paid in error, and will initiate some level of medical review until the physician has demonstrated correction of his or her billing procedures.
If a major problem is detected, the contractor will educate the physician on appropriate billing procedures, will collect the money on claims paid in error, will initiate a high level of prepayment medical review and/or a statistically valid random sample, suspend payments, and/or refer the case to the con- tractor’s Benefit Integrity department (if and when appropriate).
Physician Education and Feedback
Along with the planned medical review activities, physician feedback and education regarding the review findings is an essential part of all corrective actions. When individual reviews are conducted, focused physician education is provided. This means direct contact between the Medicare contractor and the physician through telephone contact, letter and/or face-to-face meeting. The overall goal of providing feedback and education is to ensure proper billing practices so claims will be submitted and paid correctly.
