Error rate: DME tips the scales

Thursday, February 18, 2010

BALTIMORE - The DME MAC error rate for FY 2009 was 51.9%, according to a Comprehensive Error Rate Testing (CERT) report released earlier this month by CMS.

The DME MAC error rate was higher than other types of contractors largely due to changes CMS made to its review process in 2009. Rather than allowing for clinical review judgment based on billing history and other available information, it required medical reviewers to follow the documentation requirements outlined in Medicare regulation, statute and policy.

"CMS's stricter adherence to policies disproportionally affected DME claims," the report states. "Once CMS clarified that clinical review judgment may not override documentation requirements, more errors were found on DME items."

The error rate for all Medicare fee-for-service: 7.8%. Error categories include no documentation, insufficient documentation, medically unnecessary service and incorrect coding.

The report alludes to the difficulty of obtaining appropriate documentation for DME, something industry stakeholders like AAHomecare have lamented to CMS for years.

"It is often more difficult for DME contractors to obtain the proper documentation because they request documentation from the supplier who billed for the item, not the medical professional who ordered the item," the report states. "The supplier then is responsible for submitting documentation to CMS that they have collected from the ordering provider. The involvement of multiple parties can cause a delay in documentation receipt and incomplete documentation."

In a bulletin to members last week, AAHomecare pointed out: "While a large error rate may appear troubling to policymakers, CMS notes (in the report) that 'The CERT program cannot be considered a measure of fraud.'"

To read the full report, go to: