Pilot Project to Obtain Missing Documentation Identified in the Fiscal Year 2010 CERT Program

We obtained additional documentation that enabled the Comprehensive Error Rate Testing (CERT) review contractor to overturn, or partially overturn, its claims payment denials for 46 of 136 claims (approximately 34 percent). For the remaining 90 claims, the CERT review contractor upheld its denials because providers did not produce requested documentation or the review contractor determined that the documentation we obtained did not sufficiently support the medical necessity of the claims. Based on our results, the CERT statistical contractor estimated that additional documentation to overturn claim payment denials would have reduced the FY 2010 error rate estimate from 10.5 percent to 10.2 percent, which would have reduced the estimate of improper payments by approximately $956 million.

We recommended that CMS (1) continue to educate providers on the documentation required to support the medical necessity of services and items billed to Medicare; (2) assess the improper payments identified by the CERT review contractor and the overturned denials of claim payments noted in this report to identify the population of claim payment denials that would benefit from additional requests for medical records; and (3) ensure that the CERT documentation contractor follows established procedures in seeking signature attestations when signatures on clinicians' notes are illegible or are missing and clarify existing procedures. CMS neither agreed nor disagreed with our first recommendation and disagreed with our second and third recommendations.