During the 2026 National Provider Conference in Charlotte, NC, The Centers for Medicare & Medicaid Services (CMS) officials outlined the agency’s evolving approach to medical review, contractor oversight, and program integrity, emphasizing a shift toward targeted audits and provider education rather than broad enforcement actions.
The session featured remarks from CMS Division of Medical Review Director Dan Schwartz, who provided attendees with an overview of the Medicare contractors responsible for reviewing claims, identifying billing vulnerabilities, and ensuring compliance across the Medicare program.
CMS Promotes Education-Focused Review Strategy
Schwartz described how CMS has transformed its medical review efforts over the past decade. Earlier audit initiatives often relied on broad reviews and larger claim samples. Today’s review programs, he explained, are increasingly data-driven and focused on identifying specific billing risks while providing providers with opportunities to improve documentation and compliance.
“Our goal is to reduce billing errors and improve program integrity,” Schwartz indicated during the presentation, highlighting that education has become a central component of CMS review activities.
The agency’s review framework now incorporates several types of oversight activities, including:
- Prior authorization reviews
- Pre-claim reviews
- Prepayment reviews
- Postpayment reviews
Each review type is designed to address potential billing risks at different stages of the claims process.
Role of Medicare Administrative Contractors
A significant portion of the presentation focused on Medicare Administrative Contractors (MACs), which serve as CMS’s frontline contractors for claims processing and medical review activities.
According to Schwartz, MACs function as operational hubs responsible for:
- Processing Medicare claims
- Conducting medical reviews
- Analyzing billing data
- Identifying potential vulnerabilities
- Providing provider education
- Supporting appeals activities
MACs use claims analytics and data mining tools to identify trends, prioritize resources, and target reviews toward areas where improper payments or documentation errors may be occurring.
Targeted Probe and Educate Remains Key Initiative
CMS officials highlighted the continued importance of the Targeted Probe and Educate (TPE) program, a review model designed to improve provider compliance through focused education.
Under the TPE approach:
- Reviewers typically examine a small sample of claims.
- Providers receive individualized feedback.
- Educational sessions are offered to address documentation deficiencies.
- Up to three