The Centers for Medicare & Medicaid Services (CMS) employs several strategies to ensure that payments to providers are appropriate and cover only those services that are medically necessary. One such way the Medicare Trust Fund is protected is through an active claim review program. While Beneficiary and Family Centered Care - Quality Improvement Organizations (BFCC-QIOs) like Livanta routinely provide case review services on behalf of Medicare beneficiaries, claim review services are additional activities provided by Livanta and funded by the Centers for Medicare & Medicaid Services (CMS). Claim review services represent an important activity of advancing Medicare’s triple aim of better health, better care, and lower costs.
Medicare’s claim review program includes activities that evaluate two main types of claims paid under Medicare Part A with high potential for errors: hospital inpatient admissions of short duration and claims in which hospitals paid under PPS re-submitted inpatient claims for a higher payment than what they had billed initially. In the coming weeks, Livanta will begin conducting this work in all states, territories, and Washington, D.C. As part of the review activities, Livanta’s reviewers will evaluate whether the services performed were medically necessary and paid appropriatly.