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OIG, CMS disagree on usefulness of certain CERT data 

OIG, CMS disagree on usefulness of certain CERT data 

WASHINGTON – CMS and its contractors did not use CERT data to identify providers with higher error rates, according to a new report from the Office of Inspector General. 

Using CERT data, the OIG identified 100 “error-prone” providers from 2014 through 2017. Of the $5.8 million reviewed by CERT, $3.5 million was incorrect, an improper payment rate of 60.7%. During the same period, Medicare made $19.1 billion in fee-for-service payments to those same providers. 

These providers had at least one error in each of the four years analyzed, an error rate of higher than 25% in each year, and a total error amount of at least $2,500, according to the OIG. An error-prone provider is statistically more likely to submit an improper claim than the average provider, the agency says. 

The OIG recommends CMS review the list of 100 error-prone providers identified and take specific action as appropriate, such as prior authorization, prepayment reviews and post-payment reviews, and use annual CERT data to identify individual providers that have an increased risk of receiving improper payments and apply additional program integrity tools to these providers. 

CMS did not concur with the recommendations, disagreeing with the OIG’s methodology. It also stated that it had previously tried to identify error-prone providers and suppliers using CERT data, but it found the data ineffective. 

The OIG reviewed CMS’s comments, but said its findings stand. 


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