Industry News: Highmark Medicare MAC

OVA1™ is an FDA-cleared qualitative serum test that combines the biomarker values of five immunoassays, using a proprietary algorithm, to further assess the likelihood that an ovarian mass is malignant, in women whose pre-surgical assessment did not indicate malignancy.

Highmark Medicare Services will cover OVA1™ in keeping with the FDA-cleared indication until such time that a Local Coverage Determination is developed and implemented. OVA1™ is currently indicated for women who meet the following criteria:

• Over the age of 18, and
  

During the fourth quarter, 148 CERT errors were assessed for all Part B contracts within J12. Of those 148 errors, 66 errors were due to insufficient documentation (error code 21), 47 were due to medical necessity (error code 25), 33 were due to incorrect coding (error code 31) and 2 were due to service billed were not rendered (error code 41).

As you should know, the CERT program consists of a random sample of Medicare claims selected each month which undergo an independent medical review process whereby the claims data are adjudicated against the medical records of the physician/provider. The results are analyzed and used to produce annualized estimates of the dollars paid incorrectly for each of the 15 Medicare Jurisdictions as well as Medicare nationally. This is done by statistically extrapolating the findings from the sample to the entire universe of Medicare claims.