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Non-Random Pre-Payment Medical Review Rule Finalized

The Centers for Medicare and Medicaid Services (“CMS”) recently published a final rule addressing termination of non-random prepayment complex medical review, which became effective January 1, 2009. The final rule implements Section 934 of the MMA, which required CMS to establish termination dates for non-random prepayment complex medical reviews performed by Medicare Administrative Contractors (“MACs”), or performed by intermediaries and carriers until MACs are in place. CMS will impose the same limitations on medical reviews performed by program safeguard contractors, to ensure that consistent criteria for terminating non-random prepayment review are applied to all providers and suppliers.

The final rule mandates that, in most cases and unless an exception applies, CMS will terminate a provider or supplier from non-random pre-payment complex medical review no later than one year from the initiation of the review, or when the provider’s or supplier’s error rate decreases by 70 percent from the initial error rate.

The provisions of the final rule can be found at 73 Fed. Reg. 55753 (September 26, 2008). See also 42 C.F.R. §421.501 et seq.

For more information, please call Abby Pendleton, Esq., Robert Iwrey, Esq., Adrienne Dresevic, Esq., Carey F. Kalmowitz, Esq. or Jessica L. Gustafson, Esq. at (248) 996-8510 or visit The HLP website.

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