OASIS Alert

Published on Thu Jul 08, 2004 PDF

OASIS issues are high on the list for CERT focus.

Just because you haven't heard of AdvanceMed doesn't mean you can ignore its record requests.

The Centers for Medicare & Medicaid Services has turned up the heat on agencies that fail to respond to Comprehensive Error Rate Testing (CERT) efforts.

CERT is a program to identify where your fiscal intermediary might have made an error in paying a claim that should not have been paid, said Mary St. Pierre at the National Home Care & Hospice Policy Conference in Washington in April. Some of the CERT contractors are AdvanceMed, TriCenturion and Trust Solutions, St. Pierre told the audience in the session "Responding to ADRs and Medical Review."

CERT contractors will be focusing on the same areas the FI cares most about: medical necessity, documentation to support the HIPPS code, prior hospital stay (M0175), therapy threshold, correct diagnosis code, homebound status, intermittent skilled nursing and signed and timely doctor's orders, St. Pierre reports.

Last year's poor showing in the payment error rate report -- now CMS' responsibility instead of the HHS Office of InspectorGeneral's -- led to harsh congressional criticism. For the 2003 report due in November, CMS wants to decrease the number of "non-responders."

What this means for your agency: If an agency receives a letter from the CMS CERTcontractor requesting medical records, it is required to send all requested information within 45 days (see related story "One Minor Error Can Cost You The Entire Episode Payment"). You'll know the letter is a CERT request because it will identify the sender as a "CERT Operation."

Now instead of having the contractor just send another letter after 20 and 30 days, CMS is requiring carriers and intermediaries to contact "tardy" providers as soon as 20 days after the CERT contractor's initial request. By 30 days after the CERT request, carriers and intermediaries must contact non-responding providers, says CMS in Transmittal No. 67 dated April 2.

"We believe that having [contractors] contact non-responding providers will help lower the error rate significantly," CMS says in the One-Time Notice. CMS encourages carriers and intermediaries to use phone calls rather than letters or faxes, but doesn't require it.

If the contractor doesn't receive the information within the 45 days from the date of the request, it will issue a final request. If the agency doesn't send the requested information within 10 days of the date of the final request, the contractor will refer the "recalcitrant" provider to regional OIG staff, the transmittal says. What the OIG will do with the information is unclear.

Cost: It is clear, though, that a CERT contractor can deny claims that do not meet Medicare coverage criteria just as the fiscal intermediary can, experts warn. And if you don't send records when asked, the result will be the same as if you ignored an additional development request (ADR) from your intermediary.

Failure to submit requested documents for medical review "is the number one reason for claim denials across the country," St. Pierre emphasizes.