Focused Medical Review

"Focused Medical Review" (FMR) is the process by which Medicare identifies targets for audit. As currently practiced by CMS(previously HCFA) Medicare Carriers and many private insurers, FMR identifies high dollar and/or high volume coding aberrancies and outliers, e.g., "out of the norm" billing practices. Both physician and facility billing are subject to Focused Medical Review (Medicare A and Medicare B).

Either as a stand-alone service, or a part of a Compliance Practice Analysis, BHS will identify areas of potential risk either for individual or group practices, as well as institutional FMR comparisons through Peer Comparison and Trend Analysis:

Peer Comparison

Peer Comparison is one part of the FMR process by which physicians and/or facilities billing patterns are compared to Medicare local and national same-specialty/service billing patterns.

Although most frequently performed using CPT procedure codes, ICD diagnosis and surgical procedure codes, DRG, ASC together with frequency of service and/or /length of stay, other parameters may be measured as well e.g., costs of services, discharges by type of discharge, average number of services by state, etc.

Click here for a larger view of this report.

Trend Analysis

Trend Analysis is another part of the FMR process by which physicians or facilities billing patterns are compared to local and national same-specialty billing patterns over time, (usually three to five years).

This is the methodology currently practiced by CMS and Medicare Carriers in an effort to identify inappropriate shifts in physician billing patterns by specialty, or hospital discharges, length of stay or use of DRG, e.g., aberrant trends, on both the local and national levels.

Click here to view an example of a Revenue Impact Report.