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CMS Revises Instructions for Statistical Sampling

Posted on Thursday, October 4, 2018 6:54 PM

CMS has issues Change Request (CR) 10067 which revises instructions for CMS Medicare Administrative Contractors (MACs), Recovery Audit Contractors (RACs), Supplemental Medical Review Contractor (SMRCs) and Unified Program Integrity Contractors (UPICs) on the us of statistical sampling for overpayments.

“The revised instructions require contractors to consult with its Contracting Officer’s Representative (COR)/Business Function Lead (BFL) when an overpayment is identified by data analysis alone, in addition, if CMS approves the data driven overpayment, the contractor must also consult with its COR/BFL on whether statistical sampling and extrapolation are necessary to identify the overpayment. Contractors are to consult with a statistical expert to review and approve the sampling methodology each time a sample size calculation or estimate is performed even if the methodology is applied routinely and repeatedly.”

CMS also added a requirement that the contractors must get approval from CMS before sending a letter to the supplier/provider for estimated overpayments of $500,000 or if it is an amount greater than 25% of their Medicare revenue received in the preceding twelve months. 

Source: NAHC Report

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