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2020 CERT Supplemental Improper Payment Data

Published on 

Wednesday, January 13, 2021

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In mid-November 2020, CMS published a CMS.gov Fact Sheet detailing the estimated improper payment rates for CMS Programs for Fiscal Year (FY) 2020.

Audit findings are used to calculate a Medicare Fee-for-Service (FFS) program improper payment rate. “The CERT program considers any claim that was paid when it should have been denied or paid at another amount (including both overpayments and underpayments) to be an improper payment.”

CMS reminds the reader in the Fact Sheet that improper payment rates are not necessarily indicative of or are measures of fraud. Instead, improper payments are payments that did not meet statutory, regulatory, administrative, or other legally applicable requirements and may be overpayments or underpayments.”

The following tables compares the improper payment rate for FY 2018, FY 2019, and FY 2020.

Medicare FFS (Part A and Part B) Improper Payment Rate Compare
  FY 2018 FY 2019 FY 2020
Improper Payment Rate 8.12% 7.25% 6.27%
Improper Payments $31.62B $28.91B $25.74B

Fiscal Year 2020 Supplemental Improper Payment Data

On December 21, 2020, CMS released the Supplemental Improper Payment Data Report that delves into the details behind the final Improper Payment Rate and Improper Payments. This report includes a review of claims submitted from July 1, 2018 through June 30, 2019.

 

“0 or 1 Day” LOS Claims Continued Outlier

Since the Two-Midnight Rule was implemented, the annual data has included a table comparing improper payment rates for Part A hospital claims by Length of stay. At 19.9% for 2020, the Improper Payment Rate for “0 or 1 day” LOS claims is at an all-time high since the CERT began reporting improper payments by LOS.    

Part A Inpatient PPS Length of Stay 2016 Improper Payment Rate 2017 Improper Payment Rate 2018 Improper Payment Rate 2019 Improper Payment Rate 2020 Improper Payment Rate
Overall Part A (Hospital IPPS) 4.5% 4.4% 4.8% 4.2% 4.0%
0 or 1 Day 18.6% 18.2% 17% 18.4% 19.9%
2 Days 7.1% 5.1% 6.3% 5.0% 6.3%
3 Days 4.5% 4.8% 5.0% 4.7% 4.6%
4 Days 3.4% 3.3% 4.1% 3.5% 2.3%
5 Days 2.9% 3.2% 4.4% 2.0% 2.2%
More than 5 Days 2.7% 2.6% 2.8% 2.3% 1.3%
Data Source: CERT Report Table B7

Compliance with Short Stays

Short stay reviews have been under scrutiny for several years. With the consistent increase in the improper payment rate for this patient population it is not surprising that the OIG is once again targeting short stays for review. You can read more about this in a related MMP article.

Article Author: Beth Cobb, RN, BSN, ACM, CCDS
Beth Cobb, RN, BSN, ACM, CCDS, is the Manager of Clinical Analytics 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 is a principle writer for MMP’s Wednesday@One weekly e-newsletter, an active member of our HIPAA Compliance Committee, MMP’s Education Department Program Director and co-developer of MMP’s proprietary Compliance Protection Assessment Tool.

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.