CERT Update: Improper Medicare Fee-for-Service Payments Report for November 2009 Has Been Published

The November 2009 Improper Medicare Fee-For-Service Payments Report has been published. The purpose of the CERT program is to detect and reduce Medicare waste, fraud and abuse. The national paid claims error rate in the Medicare FFS program for this reporting period is 7.8% (which equates to $24.1 B).

For this report, the CERT contractor randomly sampled approximately 99,500 claims from carriers, fiscal intermediaries and Medicare affiliated contractors. Once the CERT contractor had the sampled claims, they requested supporting medical records from the health care providers and suppliers that submitted the claims. Upon receipt of medical records, CERT reviewed the claims and the associated medical records to see if the services billed were supported and complied with Medicare coverage, coding and billing rules. When performing these reviews, the CERT contractor followed Medicare regulations, billing instructions, national coverage determinations (NCDs), coverage provisions in interpretive manuals and the respective contractor’s local coverage determinations (LCDs) and articles.

Based on the review of the medical records, claim errors were categorized into five different error categories as follows:

• No documentation – Claims were placed into this category when the provider failed to respond to repeated attempts to obtain the medical records in support of the claim.
• Insufficient documentation – Claims were placed into the category when the medical documentation submitted did not include pertinent patient facts (e.g. the patient’s overall condition, diagnosis, and extent of services performed).
• Medically unnecessary service – Claims were placed into this category when claim review staff identified enough documentation in the medical records submitted to make an informed decision that the services billed were not medically necessary based on Medicare coverage policies.
• Incorrect coding – Claims are placed into this category when providers submit medical documentation that support a lower or higher code than the code submitted.
• Other – Represents claims that do not fit into any of the other categories (e.g. service not rendered, duplicate payment error, not covered or unallowable service).

For further breakdown of errors by contractor type, you may view the entire report at https://www.cms.hhs.gov/. Select Resources & Tools, then Improper Medicare Fee-For-Service Payments Report under the Medicare heading.

If you have questions or inquiries regarding CERT, please contact us at the number or e-mail listed below and be sure to leave your name, phone number, provider number(s), CID number (if applicable) and indicate your business type (Part A, Part B, home health, hospice, federally qualified health center, or durable medical equipment supplier) and region (state).

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