One evident role of the CMS Medical Review personnel is to provide contractor oversight. They do this by providing broad direction on medical review policies. They review and approve Medicare Contractors' annual medical review strategies. Help Medicare Contractors' carry out recently passed Medicare legislation and compliance with current regulations. They also regularly monitor and evaluate MCs' performance in compliance with CMS program instructions, strategies, and goals. As well as provide continuous advice and consultation concerning the Medicare program and Medical review issues.
Much like other large Federal programs Medicare and Medicaid are vulnerable to mistakes. These mistakes result in improper payments. No matter the amount of improper payment CMS deems it unacceptable and therefore determinedly work to diminish these errors. Improper payments are not always fraudulent, as much as an error made by either a provider or one of the automated systems used to process the claims. These errors can be made easily do to the fact that there are requirements to pay Medicare promptly, and the cost and time to conduct each claim review individually would directly affect these requirements. .
Some of the most improper billing and coding errors are made by inpatient hospital providers. Some of the most common improper payments made by providers were medically unnecessary, or incorrectly coded. Also, improper payments can occur when Medicare pays a claim that should have been paid by another health plan or liable party. They also saw that with the automated system there were sometimes duplicate .
During the demonstration projects it was found that excisional debridement was the most common ICD-9-CM procedure coding error. They found that the definition of excisional debridement was not met. The most common cause of this error was misunderstanding, the physician would write debridement was performed in the medical record and the hospital coder would assign it a procedure code of 86.