Industry News: Maryland

During the third quarter, 52 CERT errors were assessed for all Part B contracts within J12. Of those 52 errors, 18 errors were due to insufficient documentation, 5 were due to medical necessity and 29 were due to incorrect coding.

During the first quarter of 2010, 158 CERT errors were assessed for all Part B contracts within Highmark Medicare Services (HMS). Of those 158 errors, 77 errors were due to insufficient documentation (error code 21), 40 were due to incorrect coding (error code 31), 38 were due to medical necessity (error code 25), and 3 was due to improper documentation submitted to the CERT contractor (error code 16).

 The Part B CERT errors that were received for Highmark Medicare Services during this quarter remain relatively unchanged from the last quarter.

Although enrolled in Medicare, many physicians and non-physician practitioners who are eligible to order items or services or refer Medicare beneficiaries to other Medicare providers or suppliers for services do not have current enrollment records in the Provider Enrollment, Chain and Ownership System (PECOS). A current enrollment record is one that is in the PECOS and also contains the National Provider Identifier (NPI). The lack of a current enrollment record in the PECOS is a result of not having submitted any enrollment information updates since November 2003.

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.