The Medicare Fee-for-Service Compliance programs prevent, reduce, and measure improper payments in FFS Medicare through medical review. We provide a number of programs to educate and support Medicare providers in understanding and applying Medicare FFS policies while reducing provider burden.
Medical Review & Education
Medical reviews involve the collection and clinical review of medical records and related information to ensure that payment is made only for services that meet all Medicare coverage, coding, billing, and medical necessity requirements.
Medicare Fee-for-Service (FFS) Recovery Audit Contractors (RACs) review claims on a post-payment basis. The RACs detect and correct past improper payments so that CMS can implement actions that will prevent future improper payments in all 50 states.
about the Medicare FFS Recovery Audit Program.
Prior Authorization & Pre-Claim Review
Through prior authorization and pre-claim review initiatives, CMS helps ensure compliance with Medicare rules.
Prior Authorization Lookup Service
Use the Prior Authorization Lookup Service to determine if Medicare Fee-for-Service requires Prior Authorization for certain items or services in your state.
Outreach & Education
Program to Evaluate Payment Patterns Electronic Report – PEPPER
PEPPER provides provider-specific Medicare data for services vulnerable to improper payments. It can be used as a guide for auditing and monitoring efforts to help providers identify and prevent payment errors. Learn more about PEPPER.
Comparative Billing Report – CBR
A CBR provides data on Medicare billing trends, allowing a health care provider to compare their billing practices to peers in the same state and across the nation. A CBR educates providers about Medicare’s coverage, coding, and billing rules and acts as a self-audit tool for providers. Get information, training, and support related to CBRs.
Provider Compliance Tips
Provider Compliance Tips are quick reference fact sheets to educate and provide high-level guidance to providers about claim denial issues and provide claim submission and documentation guidance. The tips cover Part A, B, and DME services with high Medicare improper payment rates. Access these tips and more on the Medicare Learning Network.
Improving Provider Experience
Electronic Submission of Medical Documentation – esMD
The esMD system enables providers to send medical documentation to review contractors electronically. Using the esMD system decreases costs, increases efficiency, helps improve payment turnaround time, and reduces the administrative burden of medical documentation requests and responses. Learn more about esMD.
Electronic Medical Documentation Interoperability – EMDI
EMDI engages key healthcare stakeholders in the advancement of interoperability of electronic medical records between hospitals, physicians, labs, and vendors. The primary focus of EMDI is Provider-to-Provider communications using standards similar to esMD. Learn more about EMDI.
Simplifying Documentation Requirements
Medicare is simplifying documentation requirements so that you spend less time on paperwork, allowing you to focus more on your patients and less on confusing and time-consuming claims documentation. Learn about what we are doing.
These templates and suggested clinical data elements (CDEs) are intended to help reduce the risk of claim denials and ensure that medical record documentation is more complete. Download and learn more about the clinical templates and CDEs.
Documentation Requirement Lookup Service Initiative
CMS is collaborating with ongoing industry efforts to streamline workflow access to coverage requirements, starting with developing a prototype Medicare Fee for Service (FFS) Documentation Requirement Lookup Service (DRLS).