Industry faces error rate

Errors due to insufficient documentation continue to be challenge
Friday, January 22, 2016

WASHINGTON – The CERT error rate for DMEPOS dropped to 39.1% in 2015 from an all-time high of 73.8% in 2010, but further improvements may be harder to come by.

Industry stakeholders credit HME providers for doing a better job preventing errors due to technical issues, and the DME MACs for applying policies more consistently for the dramatic decrease in the error rate in five years.

“A lot of the technical issues have been resolved,” said Wayne van Halem, president of the van Halem Group. “When providers realized how important those tiny issues were and the contractors became more consistent, they were mostly resolved.”

From 2014 to 2015, alone, the CERT error rate dropped 14%, according to the recently published supplementary appendices for the “Medicare Fee-for-Service 2015 Improper Payments Report.” (At press time, stakeholders were still waiting for the agency to publish the actual report, which will contain its interpretations of the results.)

Stakeholders acknowledge that the 39.1% error rate for DMEPOS is still very high. Because the majority of those errors are due to insufficient documentation (67.3%), further reductions will be more difficult, they say.

“That’s always going to be a challenge for HME providers, because they’re relying on physicians,” van Halem said. “In some ways, it’s out of the provider’s control.”

Stakeholders say providers are making progress, however, by requesting documentation from physicians up front, prior to submitting claims and providing equipment.

“They’re looking at the documentation before they set up patients and they’re not accepting patients until the documentation is good,” said Kim Brummett, vice president of regulatory affairs for AAHomecare. “They have to be that way. If the documentation is not good, they have to say no.”

Stakeholders say various policy changes at play could also help providers make a dent in the number of errors due to insufficient documentation, including required prior authorizations for certain DME and reinstated clinical inference by medical reviewers.

“The elimination of clinical inference has had a huge impact on increasing the error rate in the past,” van Halem said. “If it were to be reinstated, we’d easily see the error rate drop even more.”

Additionally, providers should consider the DME MACs partners and take advantage of the increasing number of resources they provide, such as the pre-claim reviews offered in jurisdictions C and D, stakeholders say.

“We are seeing the contractors really rolling up their sleeves and taking a more one-on-one approach,” said Andrea Stark, a reimbursement consultant with MiraVista.