decisionhealth Newsletters, Answer Books - 2009 Issue 3 (March)
Exclusion / Medicare Contractor Role in Exclusion / Medicare contractor role in exclusion
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Article Overview
This premium article discusses how Medicare contractors contribute to exclusion-related enforcement by recognizing billing patterns, referring potential issues, and coordinating with medical review and peer review sources. It is useful for compliance staff, auditors, and billing professionals who want to understand the contractor’s role within Medicare program integrity and exclusion processes. The article presents general guidance on contractor responsibilities, escalation pathways, and the types of supporting organizations involved in review.
Why This Topic Matters
Understanding the contractor’s role helps organizations recognize how billing and care-quality concerns may be identified and escalated in Medicare program integrity workflows.
What You Will Learn
- How Medicare contractors fit into the exclusion and program integrity process
- What kinds of concerns may prompt contractor review or escalation
- Which external review and licensing sources may be consulted in support of a case
- How contractor actions relate to fraud, abuse, and care-quality concerns
Who Should Read This
- Compliance officers
- Medical coders
- Billing staff
- Revenue cycle professionals
- Auditors
- Healthcare administrators
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