CMS targets providers that have high error rates in new claims processing, fraud reviews

To stop improper payment, prevent fraud and to be less of a burden on health systems that are processing claims correctly, CMS is now targeting for audits those providers and suppliers that have high error rates. CMS said in the August 14 notice that it is directing its Medicare Administrative Contractors to focus their medical review on specific providers and suppliers within a service, rather than all providers and suppliers billing a particular service. The contractors in the new Targeted Probe and Educate pilot will select claims for items and services that pose the greatest financial risk to the Medicare and those that have a high national error rate. Providers and suppliers with continued high error rates after three rounds of review may be subject to additional actions such as  100 percent prepay review, extrapolation or referral to a recovery auditor. Providers and suppliers may be removed from the review process after any of the three rounds of probe review, if they demonstrate low error rates or sufficient improvement