Comprehensive Error Rate Testing

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Comprehensive Error Rate Testing
A CMS Contracted Intermediary Carrier
December 2, 2003
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CERT Performance

• Assist CMS measure success of Medicare to pay
  claims correctly, assess provider behavior, and
  evaluate contractor performance.
• CMS will use contractor specific error rates as
  one component of contractor performance
  evaluations.
• CMS will use error rate findings to determine
  underlying reasons for claim errors and to
  develop appropriate action plans to improve
  compliance in payment, claims processing, and
  provider billing practices.

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CERT Goals

• By 2008
• Reduce percent of improper payments under
  Medicare FFS to 4 percent
• Have an error rate of no more than 1 percent
  above actual national paid claims error rate for
  2008
• Significantly improve provider compliance error
  rate based on 2003 baseline

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Explanation of Rates

• Paid claims error rate
• Measures dollars Carriers/DMERCs/FIs paid in
  error (net/dollars)
• Provider compliance error rate
• Measures proportion of total dollars providers
  submitted in error (net/dollars)
• Services processed error rate
• Measures errors Carriers/DMERCs/FIs make when
  processing claims (gross/services)

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Types of Cert Error Rates

Paid Claims Error Rate
Dollars overpaid Dollars underpaid Total
dollars paid
Provider Compliance Rate
Dollars submitted correctly Total dollars
submitted
Services Processed Error Rate
Number services overpaid Number services
underpaid Total number services processed
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Carrier Error Rate
Provider Compliance Error Rate
Services Processed Error Rate

Paid Claims Error Rate
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No Documentation as a Percent of the Error Rate
2002

2003
These figures have been adjusted to account for
the non-response problem experienced in 2003.
Had the adjustments not been made, 54.7 of the
9.8 paid claims error rate would have been due
to non-response, 25.9 due to insufficient
documentation, 11.3 due to medically unnecessary
services, 6.7 due to incorrect coding, and 1.4
due to other errors.
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Corrective Actions Concerning Non-Response

• CMS revised letters requesting medical records.
• Educating providers about CERT contractor
• CERT contractor will develop a mechanism to allow
  Carriers/DMERCs/FIs to see which providers have
  not responded to CERT documentation requests.
• CMS has requested funding to support an
  Electronic Medical Record (EMR) Submission Pilot
  to facilitate process and timeliness of
  submitting medical records.

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Other Corrective Actions

• CERT contractor will back out overturned appeals
  from error rate.
• CMS will make it easier for providers to find
  Medicare rules by developing a centralized
  database of national coverage, coding, and
  billing articles.
• Contractors will clarify chiropractic coverage
  and billing rules and develop procedure code
  modifiers to allow chiropractors to better
  distinguish between covered care and non-covered
  care

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Message to Providers
Please submit requested documentation.
Non-response greatly impacts the error rate. By
submitting documentation upon request, you can
help lower the error rate and prevent overpayment
request!