CERT Errors Amount to Billions in Lost Medicare Revenue
The Centers for Medicare & Medicaid Services (CMS) measures the fee-for-service (FFS) improper payment rate through the Comprehensive Error Rate Testing (CERT) program. According to a 2017 CERT report, CMS had a 90.5 percent proper payment rate and a 9.5 percent improper payment rate for all claims submitted July 1, 2015, to June 30, 2016.
Universal Common Causes of Improper Payments
The most common causes for improper payments among Part A (excluding hospital Inpatient Prospective Payment System), Part A (Hospital IPPS), Part B, and Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) were:
- Insufficient Documentation – 64.1%
- Medical Necessity – 17.5%
- Incorrect Coding – 13.1%
- No Documentation – 1.7%
- Other – 3.6%
The root causes for insufficient documentation were:
- Missing/Inadequate orders
- Missing/Inadequate plan of care
- Missing/Inadequate records
- Inconsistent records
- Certification/Recertification requirements not met
Certification/Recertification errors accounted for 50.9 percent of improper Medicare Part A (excluding IPPS) payments. More specifically, home health certification requirements often were not met.
Home health also accounts for more than $6 billion projected improper payments and the highest improper payment rate (32.3 percent) due to insufficient documentation.
Under the Part A Hospital IPPS, major joint replacement or reattachment of lower extremity wins the top spot for projected improper payments at more than $300 billion. The service with the highest improper payment rate, however, is that for chest pain, suffering an acute 30.5 percent improper payment rate.
Up-coding errors in skilled nursing facility claims resulted in more than $240 billion in projected improper payments under Part A (excluding Hospital IPPS). Whereas, infectious and parasitic disease procedures accounted for more than $158 billion in projected improper payments paid under the Part A Hospital IPPS due to up-coding errors.
The root cause for insufficient documentation in physician claims was a mixed bag:
- Multiple universal errors (36.8%)
- Missing or inadequate records (35.4%)
- Inconsistent records (19.9%)
- Missing/Inadequate orders (6.0%)
- Missing/Inadequate plan of care (0.7%)
Failing to submit documentation to support medical necessity was the root cause for the 35.4 percent error rate for missing/inadequate records.
Lab tests account for the lion’s share of projected improper payments – over a billion dollars – due mainly to insufficient documentation. Established office visits and subsequent hospital visits run a close second, with projected improper payments amounting to more than $830 million. Chiropractic claims have the highest projected error rate, however, at 41.7 percent.
The evaluation and management (E/M) codes with the highest improper payment rates due to leveling disputes are 99233, 99285, 99212, and 99231.
Hospital discharge day code 99239 had the highest improper payment rate (5.2%) due to incorrect coding.
Suppliers had a problem with missing or inadequate records to support medical necessity, too. These errors accounted for 66.2 percent of the universal errors for insufficient documentation.
Claims for oxygen supplies and equipment have the highest projected improper payments, amounting to more than $570 billion due to insufficient documentation. However, claims for upper limb orthoses have the highest projected error rate at 76.1 percent. Claims for manual wheelchairs run a close second at 73.5 percent.
Glucose monitor claims had more than $15 billion in projected improper payments due to up-coding errors.
Get All the Facts
You can find in-depth information compiled in the “2017 Medicare Fee-For-Service Supplemental Improper Payment Data” report.