If a CIA or Settlement Agreement does not include detailed Claims Review requirements, what guidelines should a provider follow?
Although not expressly required by all CIAs, the OIG suggests that Claims Reviews be conducted in accordance with the following guidelines: A Discovery Sample, of at least 50 sampling units, should be examined. The units for the Discovery Sample should be randomly selected using a random number generator or a statistically valid manual selection process (e.g., a random numbers table). For each unit reviewed, the reviewer should determine the dollar difference between the provider’s actual reimbursement and the amount the provider should have been reimbursed (based on contractor and the Centers for Medicare and Medicaid Services (“CMS”) policies). Once all sampling units have been reviewed, the results of each sampling unit are added together (underpayments may be netted or offset from overpayments). The resulting calculation is the net overpayment. The reviewer divides the net overpayment by the total dollar amount of the sample. The resulting calculation is the net financial error rat
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