Eight Tips to Speed Up the Medicare Prepayment Review Process

Tuesday, November 17, 2015
By George F. Indest III, J.D., M.P.A., LL.M., Board Certified by The Florida Bar in Health Law

Medicare providers generally recoil at the news of an impending audit.  However, being notified of a prepayment review is even worse.  In a prepayment review, health care providers are required to submit documentation to a contractor for the Centers for Medicare & Medicaid Services (CMS) before ever even receiving payment.  The health care provider subject to the review will then only receive payment (oftentimes months later) if the contractor is content with the submitted documentation.  Naturally, this can be financially distressing for the health care provider who is still responsible for the day-to-day expenses while awaiting a decision by CMS.

CMS Contractors.

If you have received notice of a prepayment review, you first need to determine the contractor that has initiated the review.  CMS contracts with four types of contractors:

(a)    Medicare Administrative Contractors (MACs);

(b)    Comprehensive Error Rate Testing (CERT) contractors;

(c)    Recovery Audit Contractors (RACs); and

(d)    Zone Program Integrity Contractors (ZPICs).

Both MACs and ZPICs have the authority to initiate prepayment reviews.

MAC Prepayment Reviews.

If a MAC notifies you of a prepayment review, know that you are suspect of improper billing for services.  If the MAC detects anything resembling fraud during the prepayment review process, it can extend review for up to one year or more.  Otherwise, MACs will generally terminate the prepayment review when the health care provider demonstrates a pattern of correct billing.  Health care providers who are notified of a MAC prepayment review should immediately consult with an experienced health care attorney at the initiation of the process.  An experienced health attorney will be able to assist the health care provider in more effectively, accurately and efficiently cooperating with the MACs to ensure a smooth and thereby speedy prepayment review.

ZPIC Prepayment Reviews.

MACs may refer certain health care providers to ZPICs for a benefit integrity prepayment review if they suspect fraud.  ZPICs can also initiate a benefit integrity prepayment review based on data analysis.  Unlike MACs, ZPICs generally are less willing to communicate with health care providers about the prepayment review.

Additionally, there are different time limitations for a benefit integrity prepayment review.  MACs' prepayment reviews are governed by Medicare Manual provisions that stipulate a maximum length of time allotted for a prepayment review.  However, a benefit integrity prepayment review can last indefinitely if the basis for the review is not timely and properly addressed by the health care provider.

Further, ZPICs make fraud referrals to the Department of Health and Human Services (HHS) Office of the Inspector General (OIG).  Thus, health care providers should view ZPICs' correspondence as the start of a potentially larger investigation.  An experienced health care attorney should be contacted immediately should you receive any communications from ZPICs.

How to Accomplish a Speedy Review.

In many cases, health care providers are subject to the Medicare prepayment review until its billing accuracy reaches a certain percentage.  However, there are other steps that can be taken to help speed up the Medicare prepayment audit process.

    (1)    Read all Correspondence from the Contractor Carefully.

    Pay close attention to all correspondence sent by the contractor.  Make a note of the due date given and make sure your response is sent well within the time limits.  Denials will usually occur if a response is not received by the given deadline.  Also be sure that you send your response to the correct office.

    (2)    Be Familiar with Local Coverage Determinations (LCDs).

    You should read and be familiar with any and all applicable local coverage determinations (LCDs) and national coverage determinations (NCDs) for any codes, services, supplies or equipment you are billing.

    (3)    Contact an Experienced Health Care Attorney Immediately.

    A health care attorney who is experienced in prepayment reviews will be able to help you file a proper response in a timely fashion.  An attorney will also be able to help find out additional information on why you have been placed on prepayment review and exactly what documentation the auditor is looking for.  Alternatively, a health care consultant who has actual experience in working on Medicare cases and who has been an expert witness in Medicare hearings may be able to assist, as well.

    (4)    Contact the Contractor Responsible for the Review.

    After you have consulted with an attorney, schedule a call with the contractor responsible for your prepayment review.  During the call learn as many details about the audit as you can and find out what the reviewer wants in the documentation.   

However, do not:

(a)    Argue with the auditor.

(b)    Berate or demean the auditor.

(c)    Challenge the auditor’s knowledge, competence or credentials.

(d)    Ask the auditor to prove anything to you.

(e)    Demand to speak to the auditor’s supervisor.

    (5)    Do Not File Duplicate Claims.

    Keep track of all requests for additional documentation and when they were received.  Do not think that you need to file another claim for the same items just because you have not received a response as quickly as other claims where additional documentation was not requested.  If you provide duplicate claims, the contractor's decision can be delayed.

    (6)    Organize all Submissions and Results.

    You must keep track of the date you receive the document request for a claim, the date you submitted the documentation for review, the result of the audit and the date the result was received.  This will help you realize how quickly claims are reviewed.  If one claim’s review has taken longer than the others you’ve submitted, you can contact the reviewer to make sure they have received the claim and everything is in order.

    (7)    Follow-up with the Contractor for Feedback.

    Keep in contact with the contractor throughout the review.  This will help to maintain the relationship you initiated after first receiving notice of the prepayment review.  This will also help you keep track of any issues and resolve them.  Be sure to discuss how you can improve your claim submissions to meet the standards of your particular reviewer.

    (8)    Review Your Documentation, Billing and Coding Processes.

    You will not be able to get off of prepayment review until your claim error rate is significantly reduced.  Usually it will need to be below ten percent (10%).  It is not necessary to perform a comprehensive review of how services are documented, coded and billed.  This process will allow the practice to identify areas susceptible to errors and can drastically reduce the duration of the prepayment review process.  Use the information learned during the review of the applicable coverage determinations to ensure that claims are accurate. 

Don't Wait Until It's Too Late; Consult with a Health Law Attorney Experienced in Medicare and Medicaid Issues Now.

The attorneys of The Health Law Firm represent health care providers in prepayment reviews. They also represent physicians, medical groups, nursing homes, home health agencies, pharmacies, hospitals and other healthcare providers and institutions in Medicare and Medicaid investigations, audits, recovery actions and termination from the Medicare or Medicaid Program.

For more information please visit our website at www.TheHealthLawFirm.com or call (407) 331-6620.


Baird, Jeff. "Q&A with Jeff Baird: How to Prepare for and Survive Prepayment Reviews." Home Care. (Sept. 13, 2010). From http://homecaremag.com/news/prepayment-review-faq-20100913/

Greene, Stephanie Morgan. "5 Steps to Get Off Pre-Payment Audit - Quickly!" Harrington Managment Group. (Mar. 18, 2011). From

About the Author:
George F. Indest III, J.D., M.P.A., LL.M., is Board Certified by The Florida Bar in Health Law.  He is the President and Managing Partner of The Health Law Firm, which has a national practice.  Its main office is in the Orlando, Florida, area.  www.TheHealthLawFirm.com  The Health Law Firm, 1101 Douglas Ave., Altamonte Springs, FL 32714, Phone:  (407) 331-6620.

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