CMS: We're on a 'mission' to find improper payments

Thursday, June 17, 2010

BALTIMORE - Under pressure by the Obama Administration to cut the national claims error rate in half, officials for CMS and its Comprehensive Error Rate Testing (CERT) contractor didn't mince words during last week's education call.

"CMS is on a mission, really, to try to get more uniformity in policy interpretations for medical review," said Dr. David Perez of AdvanceMed Corp., who's the national director of the CERT program. "That's a fair and reasonable thing."

The CERT program, in Perez's words, is designed to answer this basic question: "What are the average payment errors for the average provider?"

Most recently, in November 2009, the CERT contractor reported an error rate of 7.8%. Perez expects that rate to increase, however, now that the Office of Inspector General (OIG) has instructed CMS, which, in turn, has instructed the CERT contractor, that clinical review judgment isn't a substitute for policy, whether it's a local or national coverage determination.

If CMS and its CERT contractor had reviewed all claims for the 2009 report that stringently, he said, the error rate would have jumped from 7.8% to 12.4%.

During the call, Perez strongly emphasized the need for physicians and providers to have supporting documentation on file. Submitting an appropriate CMN, for example, isn't enough.

"I want to warn you, the physician and provider community, if you complete a CMN, it better be supported by what you wrote that day or around the time you saw the beneficiary," he said.

Perez pointed out that the number of insufficient documentation errors jumped from 0.6% in 2008 to 1.9% in 2009 and medically unnecessary errors jumped from 1.4% in 2008 to 4% in 2009.

Other highlights from the call:

*    There is no limit to the number of claims that the CERT contractor can review from one provider. Having said that, "the CERT process consists of a random sample submitted for payment and with the relatively small percentage that are actually sampled, it's unlikely that any one provider will have a large number of claims selected by CERT in any one year," said Jill Nicolaisen, technical adviser, division of error rate measurement, CMS.

*    Providers can find out why the CERT contractor has denied a claim by contacting their claims processing contractor.

*    CMS and the CERT contractor are working on a Web site that would allow providers to check the status of a review. Right now, though, their best bet is to, again, contact their claims processing contractor.