Foundations of the Billing and Collections Process

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Medical Review Policy

MRP stands for Medical Review Policy. Many providers and CAs raise an inquisitive brow when MRP is mentioned, having never even heard of it before. Make no mistake, this policy matters and plays a key role in determining the care that is reimbursable by a payor. The MRP is an administrative and educational tool designed to help providers, physicians, and suppliers submit correct claims for payment.

Medical Review Policies outline how contractors review claims and documentation to ensure that they meet coverage requirements. CMS requires MRPs to be consistent with national guidance (although they can be more detailed or specific), developed with scientific evidence, backed by clinical practice, and developed according to certain specified federal guidelines.

Contractor Medical Directors develop these policies. Understanding each carrier’s Medical Review Policy helps your employees recognize why a third party payer might pay a claim, deny it, or request documentation based on codes billed.

As you collect the Medical Review Policy for each carrier (whether you print it or digitally bookmark it), house the documents somewhere that can be accessed quickly should a question arise about sending in a claim for care or to determine who will be financially responsible for specific care. The MRP indicates the services that are considered for payment by the payor. This information is also useful if a patient wants to know why a specific type of care isn’t covered by the benefits they have available.

It is very important to review all of the stipulations in the medical review policy; be sure to consider:

  • 97140 (Manual Therapy)
  • 97124 (Massage)
  • 97112 (Neuromuscular Re-education)
  • Who can perform the services
    • Many MRPs stipulate whether certain services MUST be provided by a doctor or if they can be delegated to an employee
    • Some MRPs offer certifications that employees must have before the doctor can delegate services to them
    • Some MRPs don’t allow Independent Contractors (e.g. Massage Therapists) to work incidental to a provider under any circumstances

To find the Medical Review Policies for the payers you send claims to and are contracted with, conduct an internet search for that specific payer’s MRP. For Medicare’s review policy, each carrier usually creates Local Coverage Determinations (LCDs) that can be accessed from the Medicare carrier’s website.


By Team KMCU

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