Answer_Book / Medical_Review_of_Claims / MEDICAL_REVIEW_OF_CLAIMS

Article Overview

This article explains Medicare’s medical review process at a high level, including how claims data are screened for patterns that may signal abuse, excessive utilization, or deviations from normal practice patterns. It is useful for billing, compliance, and revenue cycle staff who want to understand the general purpose of medical review and the difference between prepayment and postpayment review. The article references Medicare Claims Manual concepts and describes the role of statistical screening and claims-data analysis without getting into code-specific guidance.