Medical Review

Resumption of Postpayment Medical Reviews

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. The Targeted Probe and Educate program (intensive education to assess provider compliance through up to three rounds of review) will restart later.

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 Railroad Medicare's Railroad Medicare's Resumption of Medical Review on a Postpayment Basis and Receiving and Responding to a Palmetto GBA Additional Documentation Request (ADR) for Postpayment Review 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

Additional Resources

Medical Review Articles

Ambulance Services ChecklistRanibizumab ChecklistMedical Review of Non-Emergency BLS TransportPortable X-Ray ChecklistChest X-Ray ChecklistRailroad Medicare and the Targeted Probe and Educate (TPE) ProcessDrug Screening ChecklistDiagnostic Radiology: Chest X-Ray ServicesMedical Review Postpayment Reviews: October 2019 to September 2020 Planned ReviewsMedical Review of Emergency ALS TransportsBone Density Study ChecklistTargeted Probe and Educate Process ModuleTargeted Probe and Educate VideoTargeted Probe & Educate (TPE) Provider ContactRituximab Check ListPalmetto GBA Partnering with Providers to Get it Right the First TimeMedical Review Intent to Reopen Process for Non-Receipt of Medical Record DenialsOverview of Prepayment and Postpayment Claim ReviewAdditional Documentation Request (ADR) Separator SheetComplying with Medicare Signature RequirementsMedical Review Program and Targeted Probe and Educate HandoutEntries in Medical Records: Amendments, Corrections and AddendaMedicare Medical Records: Signature Requirements, Acceptable and Unacceptable PracticesBone Mass Measurements (BMM) ServicesMedical Review Administrative Relief Related to the Novel Coronavirus (COVID-19) PandemicMedical Review: Additional Documentation Requests (ADRs)Chiropractic Claims Submitted with Both the 'AT' and 'GA' Modifier To RejectAlways Supply Medical Records When Requested by the Benefit Integrity UnitRailroad Medicare's Resumption of Medical Review on a Postpayment BasisRailroad Medicare's Resumption of Medical Review on a Postpayment BasisRailroad Medicare Implemented Automated Calls to Assist Providers with ADR ResponsesReceiving and Responding to a Palmetto GBA Additional Documentation Request (ADR) for Postpayment ReviewMACs Resume Medical Review on a Postpayment Basis