This week's note reviews pre-service coverage analysis processes in light of the recent CMS decision to delegate the target, probe, and educate medical review strategy to the Medicare Administrative Contractors.
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CMS determined the improper payment rate for immunosuppressive drugs was 15.7% in 2023, with a projected improper payment amount of $43.2 million. Organizations should review CMS' guidance on proper billing codes, coverage criteria, common denial reasons, and documentation requirements.
