On October 18, the Centers for Medicare & Medicaid Services (CMS) issued Transmittal 489 to its Medicare Program Integrity Manual, which provides instructions to Medicare Administrative Contractors (MACs) on 100 percent prepayment reviews and random reviews. The implementation date is November 19, 2013.
According to the transmittal, MACs have the discretion to conduct a 100 percent prepayment review of providers, which CMS considers to be appropriate when a provider has a prolonged time period of noncompliance. MACs have the discretion to conduct random reviews of services; however, CMS does not recommend random reviews. Prior to conducting a 100 percent prepayment review, the MAC must notify the CMS Contracting Officer’s Representative (COR), Regional Office Technical Monitor (TM), and Business Function Lead (BFL). Further, the MAC must provide background information on attempts to educate the provider, the historical improper payment rate of the provider before the review begins, the length of time the review is expected to take, the estimated number of claims and dollar value of claims expected to be reviewed monthly, and criteria for removing the provider from 100 percent prepayment review.
