Part B Insider (Multispecialty) Coding Alert

Published on Fri Apr 16, 2004 PDF

Don't let a non-response mar your record

If you fail to respond quickly to a record request from a CERT contractor, don't be surprised if you are almost immediately harassed.
 
The Centers for Medicare & Medicaid Services wants its payment error rate information, and it's not kidding around. CMS took over the Medicare payment error rate report from the HHS Office of Inspector General last year, and achieved a lower response rate to medical record requests than the OIG had been obtaining.
 
Then, when CMS excluded the so-called "non-responders," from its error rate figures, lawmakers harshly criticized the tactics and resulting low error rate. This year, CMS appears to be set on getting those records to complete its error rate report due in November for calendar year 2003.
 
The contractors computing the Comprehensive Error Rate Testing already send out letters on behalf of the OIG when providers fail to respond to a medical record request.
 
Now CMS is requiring carriers 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 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.
 
Contractors may contact "third-party providers" to send in relevant records, but don't have to, CMS adds in the transmittal.
 
If the CERT contractor hasn't received the requested record by 10 days after the contact, the carrier or intermediary will refer the "recalcitrant" provider to regional OIG staff, the transmittal says. What the OIG will do with the information is unclear.
 
What is clear is that before providers have a chance to catch their breath and understand the CERT record request, they could rack up an OIG referral, critics charge.
 
Plus CMS and its contractors have done a poor job of explaining to providers why CERT records are needed, who the contractors are and that the requests are legitimate, critics add. Now providers are being punished for that incompetence, they claim.