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Medical Review ContractorsMedical Review Contractors

The Centers for Medicare & Medicaid Services (CMS) uses several contractors to conduct medical review of claims and documentation, including:

Medicare Administrative Contractors (MACs), including CGSExternal Website
The MACs primarily use error rates produced by the CERT program and vulnerabilities identified through the Recovery Audit program to identify where to target their improper payment prevention efforts. The MACs analyze their internal data to determine which corrective actions would be best to prevent the CERT-identified and Recovery Auditor identified vulnerabilities in the future. The CMS has determined that most improper payments in the Medicare FFS program occur because a provider did not comply with Medicare’s coverage, coding, or billing rules. The cornerstone of the MACs’ efforts to prevent improper payments is each contractor’s Error Rate Reduction Plan (ERRP), which includes initiatives to help providers comply with the rules. These initiatives usually fall into one of three categories:

  1. Targeted provider education to items or services with the highest improper payments
  2. Prepayment and postpayment claim review targeted to those services with the highest improper payments. In addition, to encourage providers to submit claims correctly, MACs can perform extrapolation reviews as needed, and
  3. New or revised local coverage determinations, articles, or coding instructions to assist providers in understanding how to correctly submit claims and under what circumstances the services will be considered reasonable and necessary.

See section 1.3.6,External PDF for information on quality of care and potential fraud issues.

Comprehensive Error Rate Testing (CERT) contractorsExternal Website
The CMS implemented the CERT program which establishes error rates and estimates of improper payments that is compliant with the Improper Payments Elimination and Recovery Improvement Act (IPERIA).

Recovery Auditors (RAs)External Website
Although CMS, through the MACs have undertaken actions to prevent future improper payments, it is difficult to prevent all improper payments, considering that the Medicare FFS program processes more than 1 billion claims each year. The CMS uses the Recovery Audit program to detect and correct improper payments in the Medicare FFS program and provide information to CMS and review contractors that could help protect the Medicare Trust Funds by preventing future improper payments.

Unified Program Integrity Contractors (UPICs)External Website
The Unified Program Integrity Contractors (UPICs) perform fraud, waste, and abuse detection, deterrence and prevention activities for Medicare and Medicaid claims processed in the United States. Specifically, the UPICs perform integrity related activities associated with Medicare Parts A, B, Durable Medical Equipment (DME), Home Health and Hospice (HH+H), Medicaid, and the Medicare-Medicaid data match program (Medi-Medi). The UPIC contracts operate in five (5) separate geographical jurisdictions in the United States and combine and integrate functions previously performed by the Zone Program Integrity Contractor (ZPIC), Program Safeguard Contractor (PSC) and Medicaid Integrity Contractor (MIC) contracts.

Supplemental Medical Review Contractor (SMRC)External Website
The Supplemental Medical Review Contractor’s (SMRC) main tasks are to perform and/or provide support for a variety of tasks aimed at lowering the improper payment rates and increasing efficiencies of the medical review functions of the Medicare and Medicaid programs. Having a centralized medical review (MR) resource that can perform large volume MR nationally allows for a timely and consistent execution of MR review, activities and decisions. The focus of the reviews may include but are not limited to issues identified by CMS internal data analysis, the CERT program, professional organizations and other Federal agencies, such as the OIG/GAO and comparative billing reports.


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