The Federal Government estimates that about 12.7 percent of all Medicare Fee-For-Service (FFS) claim payments are improper. The overall goal is to reduce improper payments by identifying and addressing coverage and coding billing errors for all provider types.
The Centers for Medicare & Medicaid Services (CMS) implemented several initiatives to prevent or identify and recover improper payments before CMS processes a claim, and to identify and recover improper payments after processing a claim.
Med-Prov supports health plans, Program Safeguard Contractors, Clinical Practices, and Federal and State Agencies by providing clinical reviews, coding audits, supporting appeals process, and reviewing coding practices to prevent risk and vulnerabilities. Our mission is to monitor and track policies and regulations an support the missions of the CMS initiatives to prevent, idietnry and reduce risk of improper billing using audit, self-disclosures, and education and outreach.
Med-Prov supports a variety of reviews including;
- Prepayment Review: Review of claims prior to payment. Prepayment reviews result in an initial determination.
- Postpayment Review: Review of claims after payment. Postpayment reviews may result in either no change to the initial determination or a revised determination, indicating an underpayment or overpayment.
- Underpayment: A payment a provider receives under the amount due for services furnished under Medicare statute and regulations.
- Overpayment: A payment a provider receives over the amount due for services furnished under Medicare statute and regulations.
Common reasons for overpayment are:
- Duplicate submission and subsequent payment of the same service or claim;
- Payment to an incorrect payee;
- Payment for excluded or medically unnecessary services;
- Payment for services that were furnished in a setting that was not appropriate to the patient’s medical needs and condition; or Billing for excessive or non-covered services.
