When Does Non-Random Prepayment Complex Medical Review End?
Generally speaking, in most cases and unless an exception applies, a Medicare contractor will terminate a provider or supplier from review no later than one year from the initiation of the review, or when the provider’s or supplier’s error rate decreases by 70 percent from the initial error rate. The Medicare contractor will evaluate the provider’s or supplier’s error rate on a quarterly basis. In most cases, non-random prepayment complex medical review will end, at the latest, one year from its initiation. At the conclusion of the one-year timeframe for review, if the Medicare contractor determines that the provider or supplier continues to have a high error rate, the Medicare contractor is mandated to consider the following: Referring the provider or supplier to Benefit Integrity Review Continuing educational interventions (without performing further medical review) Initiating a post-payment audit In some cases, the one-year time limit for non-random prepayment complex medical review
