CERT Supplemental Improper Payment Data Report

on Wednesday, 02 January 2019. All News Items | Case Management | Medicare Coverage | Billing

2018 CERT Report Released November 30, 2018

According to the Payment Accuracy.gov website “The Improper Payments and Elimination and Recovery Act of 2010 defines an “improper payment” as any payment that should not have been made or that was made in an incorrect amount under statutory, contractual, administrative, or other legally applicable requirements.”

The Comprehensive Error Rate Testing (CERT) Program calculates improper payment rates for the Medicare Fee-for-Service program. This article focuses on the CERT Program and Review Process and findings from the 2018 CERT Report.

 

CERT Program & Review Process

Medical Record Request

For each reporting period, the CERT Program selects a stratified random sample of approximately 50,000 claims submitted to Part A/B Medicare Administrative Contractors (MACs) and Durable Medical Equipment MACs (DMACs). This sample include claims that were paid or denied by the MAC.

When the CERT requests medical records from a provider if no documentation is received within 75 days of the initial request, the claim is classified as a “no documentation” claim and counted as an error. However, the CERT will still review documentation received after 75 days as long as it’s before the end of the report period deadline.

Review of Claims

Medical review professionals perform complex medical reviews to determine whether a claim was paid properly under Medicare coverage, coding and billing rules. Claim reviewers includes nurses, medical doctors and certified coders. This group of Medical review professionals assign improper payment error categories.

Improper Payment Error Categories, Definitions, and Examples

In a CMS Introduction to CERT download on the CMS CERT webpage, the following examples are provided specific to each improper payment category.

Improper Payment by Category
Error CategoryCategory DescriptionCMS Example
Insufficient Documentation

The documentation is insufficient to determine whether the claims was payable. This occurs when:

  • Medical documentation submitted is inadequate to support payment
  • It could not be concluded that the billed services were actually provided, were provided at the level billed, and/or were medically necessary
  • A special documentation element, that is required as a condition of payment is missing
A hospital billed for infusion of a medication provided in the outpatient department. The CERT program received a visit note to support the medical necessity of the medication. However, the order and the administration record for the infusion were missing.
Medical Necessity

Medical documentation supports:

  • Services billed were not medically necessary based upon Medicare coverage and payment policies.
A provider billed for an inpatient rehabilitation facility (IRF) stay. There was not a reasonable expectation that the beneficiary was able to benefit from an intensive rehabilitation program because she was completely independent.
Incorrect Coding

Medical Documentation supports:

  • A different code than what was billed
  • The service was performed by someone other than the billing provider
  • The billed service was unbundled
  • The beneficiary was discharged to a site other than the one coded on the claim
A provider billed for Healthcare Common Procedure Coding System (HCPCS) code 99214. The submitted documentation did not meet the requirements for 99214 but met the requirements for 99213.
No Documentation The provider or supplier fails to respond to repeated requests for the medical records. A supplier billed for diabetic testing supplies. The provider did not submit any medical records to support the claim.
Other An improper payment that does not fit into any of the other error categories. A DMEPOS supplier billed for an upper limb orthosis, which the CMS Pricing, Data Analysis and Coding (PDAC) contractor determined was classified as exercise equipment. Exercise equipment is not covered by Medicare.
Link to Download: https://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/Medicare-FFS-Compliance-Programs/CERT/Downloads/IntroductiontoComprehensiveErrorRateTesting.pdf

 

Calculation of the Improper Payment Rate.

CMS calculates a national improper payment rate and contractor specific and service specific improper rates from this stratified random sample of claims. As noted on the CMS CERT webpage, “The improper payment rate calculated from this sample is considered to reflect all claims processed by the Medicare FFS program during the report period.”

CMS notes “that the improper payment rate is not a “fraud rate,” but is a measurement of payments that did not meet Medicare requirements. The CERT program cannot label a claim fraudulent.”

 

2018 CERT Report by the Numbers:

Annually, the Department of Health and Human Services (HHS) publishes the improper payment rate in the Agency Financial Report. CMS later publishes more detailed improper payment rate information in the form of the annual Medicare FFS Improper Payments Report and Appendices.  CMS published the

2018 Medicare Fee-for-Service Supplemental Improper Payment Data Report on November 30, 2018. This report includes a review of claims submitted from July 1, 2016 through June 30, 2017.  

Overall

Overall Percent Accuracy Rate – 91.9% - Improper Payment Rate $357.7B

Percent Improper Payment Rate – 8.1% - Improper Payment Rate $31.6B

Common Causes of Improper Payments

Below is a table comparing the common causes of improper payments are broken out by the type of error. It appears that providers are doing better at submitting medical records. However, Medical Necessity errors are on the rise.

 

Common Causes of Improper Payments Compare
 2017 Report2018 Report
Insufficient Documentation 64.1% 58.0%
Medical Necessity 17.5% 21.3%
Incorrect Coding 13.1% 11.9%
No Documentation 1.7% 2.6%
Other 3.6% 6.3%

 

“0 or 1 Day” LOS Claims Continued Outlier

The CERT Program has reported Projected Improper Payments by Length of Stay (LOS) since the 2014 Report. While the Improper Payment Rate has dropped for “0 or 1 day” LOS claims, this group of claims continues to have the highest improper payment rate.

Part A Inpatient PPS Length of Stay2016 Report2017 Report2018 Report
Number of Claims SampledImproper Payment RateNumber of Claims SampledImproper Payment RateNumber of Claims SampledImproper Payment Rate
Overall Part A(Hospital IPPS) 14,490 4.5% 14,500 4.4% 13,499 13.4999%
0 or 1 day 1,689 18.6%↓ 1,685 18.2%↓ 1,511 17%↓
2 days 2,315 7.1% 2,465 5.1% 2,219 6.3%
3 days 2,485 4.5% 2,742 4.8% 2,199 5%
4 days 1,739 3.4% 1,723 3.3% 1,715 4.1%
5 days 1,286 2.9% 1,245 3.2% 1,201 4.4%
More than 5 days 4,976 2.7% 4,950 2.6% 4,744 2.8%
Data Source: CERT Report Table B7

Compliance with Short Stays

Have you tracked your short stay volume overall, by MS-DRG or Physician over time? Do you know if your hospital is an outlier? Where can you look to find these answers?   

 

PEPPER

One resource available to hospitals is the Short-Term Acute Care PEPPER (Program for Evaluating Payment Patterns Electronic Report). The PEPPER is made available to hospitals on a quarterly basis and compares your hospital to your state, MAC Jurisdiction and the nation. One-day Stays for Medical and Surgical MS-DRGs are two of the “Target Areas” at risk for improper payments included in this report.

The PEPPER provides the following suggested interventions for high One-day Stays Hospitals:  

“This could indicate that there are unnecessary admissions related to inappropriate use of admission screening criteria or outpatient observation. A sample of same- and/or one-day stay cases should be reviewed to determine if inpatient admission was necessary or if care could have been provided more efficiently on an outpatient basis (e.g., outpatient observation). Hospitals may generate data profiles to identify same- and/or one-day stays sorted by DRG, physician or admission source to assist in identification of any patterns related to same- and/or one-day stays. Hospitals may also wish to identify whether patients admitted for same- and/or one- day stays were treated in outpatient, outpatient observation or the emergency department for one or more nights prior to the inpatient admission. Hospitals should not review same- and/or one- day stays that are associated with procedures designated by CMS as “inpatient only.”

 

RealTime Medicare Data

Another source that can help assist you is our sister company, RealTime Medicare Data (RTMD). RTMD collects over 800 million Medicare Fee-for-Service paid claims annually from 23 states and the District of Columbia, and allows for searching of over 7 billion historical claims. In response to the “Two-Midnight” Policy, RTMD has available in their suite of Inpatient Hospital reports a One Day Stay Report. To give you a true picture of your “at risk” volume, this report excludes claims with a discharge status for Expired (20), left against medical advice (07), hospice (50 & 51) and /or were transferred to another Acute care facility (02). This report enables a hospital to view one day stay paid claims data by DRG and Physician to direct where audits should be focused. For further information on all that RTMD has to offer you can visit their website at www.rtmd.org.

 

To learn more about the CERT visit AdvanceMed’s CERT Provider Documentation Information website at https://certprovider.admedcorp.com/Home/About.

 

Article by Beth Cobb

Beth Cobb, RN, BSN, ACM, CCDS, is the Manager of Clinical Services at Medical Management Plus, Inc.  Beth has over twenty-five years of experience in healthcare including eleven years in Case Management at a large multi-facility health system.  In her current position, Beth monitors, interprets and communicates current and upcoming Case Management / Clinical Documentation issues as they relate to specific entities concerning Medicare.  You may contact Beth at This email address is being protected from spambots. You need JavaScript enabled to view it..

This material was compiled to share information.  MMP, Inc. is not offering legal advice.  Every reasonable effort has been taken to ensure the information is accurate and useful.

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