A new OIG (Office of Inspector General) report has been released that is important to review. The title is: CMS and Its Contractors Did Not Use Comprehensive Error Rate Testing (CERT) Program Data To Identify and Focus on Error-Prone Providers (A-05-17-00023).

See the OIG summary information below:   

OIG Report: CMS and Its Contractors Did Not Use Comprehensive Error Rate Testing Program Data To Identify and Focus on Error-Prone Providers (A-05-17-00023)
 
 The Centers for Medicare and Medicaid Services and its contractors did not use Comprehensive Error Rate Testing (CERT) data to identify and focus on error-prone providers for review and corrective action. Using CERT data, we identified 100 error-prone providers from 2014 through 2017. Of the $5.8 million reviewed by CERT, $3.5 million was incorrect, which is an improper payment rate of 60.7 percent. We determined that during the same period, Medicare made $19.1 billion in FFS payments to these 100 error-prone providers.

 The term “error-prone provider” is an OIG-created term to refer to a list of providers identified as having higher rates of errors in the CERT sample data. When used to describe OIG analysis of CERT data from 2014 through 2017, the term refers to providers that had at  least one error in each of the 4 CERT years analyzed, an error rate of higher than 25 percent in each of the 4 CERT years analyzed, and  a total error amount of at least $2,500. An error-prone provider is statistically more likely to submit an improper claim than the average  provider.

This OIG report on CERT is also an excellent reminder to us in the Fee-For-Service (FFS) world to look at where CMS payment errors occur and what type errors are most often found. The 2020 CERT report on improper payments indicates that the three top causes for Medicare payment errors are:

  • Insufficient documentation = 63.1%
    • Medical necessity = 16.2%
    • Incorrect coding = 10.9%

You can locate the annual CERT reports at: www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/Medicare-FFS-Compliance-Programs/CERT/CERT-Reports

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