decisionhealth Newsletters, Answer Books - 2009 Issue 9 (September)
Medical Review of Claims / Comprehensive MR Signals Serious Problems
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Article Overview
This premium article provides an overview of Medicare’s medical review process, with emphasis on the more intensive comprehensive medical review pathway. It is aimed at readers who need to understand how claims may be screened for questionable billing patterns, how cases may be selected for closer examination, and how carrier review activity is organized. The discussion focuses on general review concepts, selection factors, and program context rather than code-level guidance.
Why This Topic Matters
Understanding how Medicare escalates from routine review to comprehensive medical review helps readers interpret claim scrutiny and the kinds of concerns that may trigger deeper carrier attention.
What You Will Learn
- How Medicare distinguishes routine medical review from comprehensive medical review
- What broad factors may prompt a case to receive more intensive review
- How carrier staff may identify claims or providers for closer examination
- Why this review process matters for suspected overutilization or other irregular patterns
Who Should Read This
- Medical coders
- Billing staff
- Compliance personnel
- Physicians
- Suppliers
- Healthcare administrators
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