Medical Review

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.

Additional Resources

Medical Review Articles

Targeted Probe and Educate Progress Update: Ambulance Services A0426-A0428Targeted Probe and Educate VideoTargeted Probe and Educate Progress Update: JJ 99291-99292: Critical Care First HourTargeted Probe & Educate (TPE) Provider ContactMedical Review Administrative Relief Related to the Novel Coronavirus (COVID-19) PandemicTargeted Probe and Educate Progress Update: JJ E/M 99232-99233: Subsequent Hospital CareTargeted Probe and Educate Progress Update: JJ Ambulance A0427-A0429: Ambulance Services (Emergent)Targeted Probe and Educate (TPE) ProcessTargeted Probe and Educate Progress Update: JJ 99214/99215 Evaluation and Management: Established Patient Office VisitsCritical Care ChecklistWe Have Noticed a Significant Increase in 296 Auto Denials - Requested Records Not SubmittedMACs Resume Medical Review on a Post-Payment BasisReceiving and Responding to a Palmetto GBA Additional Documentation Request (ADR) for Postpayment ReviewHyperbaric Oxygen ChecklistOrders Issued Through Text MessagingCharge Denial Rate (CDR) CalculatorMedical Review Intent to Reopen Process for Non-Receipt of Medical Record DenialsAttestation StatementsMedical Review: Additional Documentation Requests (ADRs)Outpatient Therapy (OT) Exercises ChecklistErrors in Emergency Department ServicesPalmetto GBA Partnering with Providers to Get it Right the First TimeActive Service Specific Postpayment Medical ReviewsOutpatient Department Prior Authorization CalculatorOutpatient Hospital Department (OPD) Prior Authorization (PA) Fax NumberOutpatient Department (OPD) Prior Authorization (PA) Required DocumentationOutpatient Department (OPD) Prior Authorization (PA) Alert!Prior Authorization Process for Certain Hospital Outpatient Department (OPD) Services Frequently Asked QuestionsOutpatient Department (OPD) Prior Authorizations (PA)Blepharoplasty and Blepharoptosis RepairPrior Authorization for Certain Hospital Outpatient Department (OPD) Services TerminologyOutpatient Department Prior Authorization (OPD) eServices Submission GuideRhinoplastyOutpatient Department (OPD) Prior Authorization (PA) Part 1 Program OverviewOutpatient Department (OPD) Prior Authorization (PA) ExemptionVein Ablation and Related ServicesThe Prior Authorization (PA) Program for Certain Hospital Outpatient Department (OPD) Services Operational GuideComplying with Medicare Signature RequirementsDocumentation Tips for Ambulance Providers: Paint the PictureMedical Review Program and Targeted Probe and Educate HandoutTop 10 Medical Review Denials ModuleTargeted Probe and Educate Process ModuleMedicare Medical Records: Signature Requirements, Acceptable and Unacceptable PracticesADR Response CalculatorAccess TPE Letters Electronically Job AidesMD for the Review Choice Demonstration (RCD) and the Outpatient Department (OPD) Prior Authorization (PA)Medicare Record Authentication: Tips for PhysiciansPanniculectomyBotulinum Toxin InjectionsOutpatient Department (OPD) Prior Authorization (PA)Postpayment Service-Specific Probe Results for Surgical Services: Extracapsular Cataract Removal with Insertion for October to December 2020ADRs for Outpatient Department Prior Authorization services (OPD PA) Services