Review of Statistical Methods Within the Medicare Fee-For-Service Administrative Appeal Process

Medicare program integrity contractors are authorized to use statistical sampling to identify and recover improper payments. Providers may contest these statistical estimates through the administrative appeals process. If a statistical estimate is overturned during the administrative appeals process, then the provider is liable for any overpayment upheld in the sample rather than the full, extrapolated total. The difference between these amounts is often substantial. The Medicare Administrative Contractors (MACs) and Qualified Independent Contractors (QICs) are responsible for the first two levels of the appeals process and thus play a critical role in deciding which extrapolations will be upheld. We will determine whether the MACs and QICs are reviewing statistical estimates in an appropriate and consistent manner as part of the fee-for-service appeal process.

Announced or Revised	Agency	Title	Component	Report Number(s)	Expected Issue Date (FY)
Completed	Centers for Medicare & Medicaid Services	Review of Statistical Methods Within the Medicare Fee-For-Service Administrative Appeal Process	Office of Audit Services	A-05-18-00024; W-00-18-35806	2021