CMS Issues Guidance to Change Medical Reviewer Requirements for Complex Medical Reviews

Effective September 12, 2017, the Centers for Medicare & Medicaid Services (CMS) will implement changes to ensure that complex reviews for coverage determinations are performed by Registered Nurses (RNs), therapists, or physicians with limited exceptions. Change Request 10157, issued on August 11, 2017, instructs certain Medicare contractors, including Medicare Administrative Contractors (MACs), Recovery Audit Contractors (RACs), Zone Program Integrity Contractors (ZPICs), and Comprehensive Error Rate Testing (CERT), that they can no longer hire new Licensed Practical Nurses (LPNs) to perform complex reviews for Medicare coverage determinations. LPNs who are currently employed to perform complex medical review are grandfathered in to perform such reviews. The Change Request also proactively adds therapists to the list of professional providers who may perform complex review.

The goal of the Medicare Medical Review (MR) program is to reduce payment error for Medicare reimbursed services by preventing initial payments of claims that do not comply with Medicare regulations and requirements for coverage, coding, payment or billing policies. As part of the program, Medicare contractors analyze data, such as provider profiles and beneficiary utilization, to identify providers who are not in compliance with coding, billing, coverage, and other payment and billing policies. Contractors typically initiate complex medical reviews to focus on an identified problem area to help determine the appropriate corrective action to undertake (such as provider eduction, postpayment review, or prepayment review).

Generally, LPNs require about a year of nursing education although the requirements vary from state to state. In comparison, RNs must have, at a minimum, a two-year degree and often have a three-year diploma. Although the changes will limit the pool of nursing professionals who may perform complex medical reviews, the Medicare guidance will ensure that professionals performing complex medical review have more robust clinical education, training, or experience with the medical review process.

For questions regarding Change Request 10157 and how your organization can ensure compliance with Medicare’s coding, billing, payment, and billing policies, please contact Lanchi N. Bombalier or Genevieve M. Razick.

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