A Guide to Peer Review Organizations (PROs) and Medicare Claim Reviews

Peer Review Organizations (PROs) are independent organizations that are contracted to the Centers for Medicare & Medicaid Services (CMS) to review the quality of healthcare services provided to Medicare beneficiaries. PROs provide an impartial review of the medical records of the healthcare services provided and are tasked with ensuring that the claims submitted by healthcare providers are medically reasonable and necessary. The review of the healthcare services by these organizations helps to ensure the accuracy of the claims and protect the Medicare program from fraudulent or improper payments.

The Role of PROs in the Medicare Program

PROs are responsible for reviewing the quality of care provided to beneficiaries in the Medicare program. They review medical records and assess whether the care provided was medically necessary, covered by Medicare, and performed in accordance with accepted standards of practice. The PROs evaluate the documentation and medical records to ensure that the procedure or procedure was performed appropriately and correctly without any discrepancies.

The review and approval of healthcare claims by PROs is a critical part of ensuring the integrity of Medicare. PROs provide an independent review of the medical services provided and verify that Medicare beneficiaries have received appropriate care. This helps to protect the program from fraudulent or improper payments, ultimately saving money and protecting the Medicare trust fund.

How Do PROs Approve or Deny Claims?

When evaluating a claim, PROs review the medical records to assess whether the care provided was appropriate and medically necessary. They must also determine if the care was covered by Medicare and confirm that the medical procedures were performed according to accepted standards of practice. If the claim does not meet the criteria set forth by the PRO, the claim may be denied.

It is also important to note that PROs are not tasked with determining if the patient was satisfied with the care they received, only that it was appropriate and medically necessary under the Medicare program. If the care was deemed appropriate and medically necessary, the healthcare provider is eligible to receive payment.

Conclusion

The review and approval of Medicare claims by PROs is a critical part of protecting the program from fraudulent or improper payments. PROs provide an impartial review of the medical records and assess if the care provided was appropriate, medically necessary, and covered by Medicare. By ensuring that the claims are accurate, PROs help to protect the Medicare program and save money.