Wednesday, June 30, 2004

CERT reviews and HIPAA rules
With Jim Walsh
J. Walsh

Q. Our HME has received a letter from a company named AdvanceMed, which indicated that some of our claims were selected as part of a random CMS review. The letter asks for submission of medical records and detailed supporting documentation. Isn’t this a HIPAA issue, that is, won’t we need patient authorizations to release this information?

A. Let me begin with “who is AdvanceMed.” CMS developed a program titled CERT, or Comprehensive Error Rate Testing, to determine paid claim error rates. As a Medicare Program Safeguard Contractor, AdvanceMed has been authorized, pursuant to Section 1893 of the Social Security Act, to conduct audits and reviews for CMS.

The CERT program’s independent reviewers periodically review random samples of Medicare claims. The independent reviewers look at claims that are paid and claims that are denied to ensure that the decision was appropriate. The outcomes are a provider compliance error rate, paid claims error rate, and a claim’s processing error rate.

With regard to HIPAA, the Privacy Rule permits disclosure of personal health information to carry out “treatment, payment or health care operations.” Upon enrollment, beneficiaries are informed of Medicare’s use of their personal health information to carry out health care operations. AdvanceMed performs health care operations as a business associate of CMS with respect to the HIPAA Privacy Rule, so providing the requested documentation does not violate the HIPAA Privacy Rule and does not require beneficiary authorization. This analysis would apply to any authorized Medicare audit contractor.

In any case, the requested information must be returned to AdvanceMed within 45 days of the receipt date on the letter. Failure to respond to the request, or submission of incomplete medical records, will result in a claim/claim line denial or reduction in payment. The overpayment will be recovered through the affiliated contractor’s internal claim adjustment process.

Jim Walsh is the president of VGM Management. He can be reached at 319-274-6510.