Program_Memos / 2002 / B-02-007

Why This Topic Matters

The memorandum describes the framework carriers use to support statistically based overpayment estimates in Part B claim reviews. Understanding the guidance helps organizations evaluate review methodology, documentation, and downstream actions tied to sampling-based determinations.

Article Sections

1. Introduction

   Overview of the memorandum’s purpose, scope, and intended use in Medicare carrier administrative reviews.

2. Probability Sampling

   General requirements for probability-based sample selection and the statistical properties expected of the method.

3. Selection of Period to be Reviewed and Composition of Universe

   Guidance on defining the review period, universe, sampling unit, and sampling frame.

4. Sample Selection

   Discussion of sample design options, random number selection, sample size considerations, and documentation of methodology.

5. Calculating the Estimated Overpayment

   General approach to estimating overpayment amounts and handling results from sampled claims.

6. Actions to be Performed Following Selection of Physician or Supplier and Sample

   Notification, review-site, meeting, and claim review procedures after a physician or supplier has been selected.

7. Overpayment Recovery

   Post-review recovery steps, demand letter content, and related administrative follow-up.

8. Corrective Actions

   Other administrative actions that may follow a review, including program integrity measures.

9. Changes Resulting from Appeals

   How appeal outcomes may affect the sampling methodology or revised determinations.

10. Appendix A

    Reference list of statistical sampling resources cited by the memorandum.

11. Appendix B

    Additional discussion of stratified and cluster sampling concepts and considerations.