MODERNIZED AHFI COMPLETE
SOLUTION EXAM 2025
MACs and non-random service-specific prepayment reviews
MACs are encouraged to initiate non-random service-specific
prepayment review to prevent improper payments for services
identified by C ERT or Recovery Auditors or other sources.
MACs and prepayment reviews (2)
MACs have the discretion to conduct 100% prepayment review of
providers
CMS considers 100% prepayment review to be appropriate when
A provider has a prolonged time period of non-compliance with CMS
policies.
*Any Mac that plays to conduct 100% prepayment review shall inform
the CMS Cor, Regional Office TM and BFL in advance about any provider
being placed on 100% prepayment review. In addition the Mac shall
provide
,1) Background information on attempts to educate the provider
2) The historical improper payment rate of the provider before
beginning 100% prepayment review
3) The length of time the provider is expected to be on 100%
prepayment reviews.
4) The estimated number of claims and $$ value of claims expected to
be reviewed/month
5)The criteria for removing the provider from 100% prepayment
review.
6 stages of an investigation
Detection
Assessment
Investigative strategy
Case investigation
Report writing
Determination of action
,2) The primary objective of the assessment phase is to establish
________
PREDICATION for the continued investigation
1) Detection
The process of uncovering potential fraud, waste and abuse utilizing
human and technical resources and techniques
3) Investigative strategy
Developing an Investigative plan to identify and gather evidence to
support the statutory elements to prove the case
4) Case Investigation
The process of utilizing legal and appropriate techniques to prove or
disprove the allegations
5) Report Writing
, The process of documenting the Investigative tasks in a final
comprehensive Investigative report
6 Determination of Action
Evaluating the totality of the documented case facts to determine the
best action to resolve the investigation.
Detection phase involves
Behavioral & Pattern Analysis
Emerging Schemes
Hot Spots
LE = Law Enforcement (Intelligence, Vice, OC)
Payer: Sales, Claims, Provider Relations, Legal
Hotline (Patients, Providers & Employees)
NHCAA (RIA & SIRIS)
Information Sharing (SIU, Anti-fraud Organizations, Task Force)
SOLUTION EXAM 2025
MACs and non-random service-specific prepayment reviews
MACs are encouraged to initiate non-random service-specific
prepayment review to prevent improper payments for services
identified by C ERT or Recovery Auditors or other sources.
MACs and prepayment reviews (2)
MACs have the discretion to conduct 100% prepayment review of
providers
CMS considers 100% prepayment review to be appropriate when
A provider has a prolonged time period of non-compliance with CMS
policies.
*Any Mac that plays to conduct 100% prepayment review shall inform
the CMS Cor, Regional Office TM and BFL in advance about any provider
being placed on 100% prepayment review. In addition the Mac shall
provide
,1) Background information on attempts to educate the provider
2) The historical improper payment rate of the provider before
beginning 100% prepayment review
3) The length of time the provider is expected to be on 100%
prepayment reviews.
4) The estimated number of claims and $$ value of claims expected to
be reviewed/month
5)The criteria for removing the provider from 100% prepayment
review.
6 stages of an investigation
Detection
Assessment
Investigative strategy
Case investigation
Report writing
Determination of action
,2) The primary objective of the assessment phase is to establish
________
PREDICATION for the continued investigation
1) Detection
The process of uncovering potential fraud, waste and abuse utilizing
human and technical resources and techniques
3) Investigative strategy
Developing an Investigative plan to identify and gather evidence to
support the statutory elements to prove the case
4) Case Investigation
The process of utilizing legal and appropriate techniques to prove or
disprove the allegations
5) Report Writing
, The process of documenting the Investigative tasks in a final
comprehensive Investigative report
6 Determination of Action
Evaluating the totality of the documented case facts to determine the
best action to resolve the investigation.
Detection phase involves
Behavioral & Pattern Analysis
Emerging Schemes
Hot Spots
LE = Law Enforcement (Intelligence, Vice, OC)
Payer: Sales, Claims, Provider Relations, Legal
Hotline (Patients, Providers & Employees)
NHCAA (RIA & SIRIS)
Information Sharing (SIU, Anti-fraud Organizations, Task Force)
