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Audit (A-01-10-01000)

Analysis of Errors Identified in the Fiscal Year 2009 Comprehensive Error Rate Testing Program

Executive Summary

Our review found that six types of health care providers accounted for $4.4 million, or 94 percent, of the $4.7 million in improper payments identified by CMS’s Comprehensive Error Rate Testing (CERT) contractor for fiscal year (FY) 2009. The provider types comprised inpatient hospitals, durable medical equipment suppliers, hospital outpatient departments, physicians, skilled nursing facilities, and home health agencies. As part of the Medicare error rate process, the CERT contractor conducted medical record reviews of a random sample of paid claims from all types of providers. Based on the results of those reviews, CMS reported to Congress that the national Medicare error rate for FY 2009 was 7.8 percent, or $24.1 billion. The Improper Payments Information Act of 2002 requires that CMS estimate improper Medicare fee-for-service payments each year.

Our analysis of the erroneous claims identified by the CERT contractor found that three types of errors accounted for about 98 percent of the $4.4 million in improper payments attributable to the six types of providers:

  • insufficient documentation, e.g., missing clinical notes or test results and missing, incomplete, or illegible physician orders, which resulted in improper payments totaling $2.6 million;
  • miscoded claims, which resulted in improper payments totaling $0.9 million; and
  • medically unnecessary services and supplies, which resulted in improper payments totaling $0.8 million.

We recommended that, as part of its analysis of the FY 2009 CERT improper payments, CMS use the results of our analysis in identifying (1) the types of payment errors indicative of programmatic weaknesses and (2) any additional corrective actions needed to strengthen the CERT program. CMS concurred with our recommendation.

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