Oversight and Evaluation of the Fiscal Year 2003 Comprehensive Error Rate Testing Program

EXECUTIVE SUMMARY:

The objectives of this review were to determine whether (1) the Comprehensive Error Rate Testing (CERT) contractor followed established CERT error rate review policies and procedures and (2) the CERT quality assurance program ensured the reliability of the CERT claims review process.  Our review of 105 claims found that the CERT contractor generally followed established CERT error rate review policies and procedures for 99 claims.  However, the medical records for six claims were never received, and letters requesting medical records were often sent late.  In addition, our review of another 45 claims found that the CERT contractor had not fully implemented the quality assurance program in accordance with established procedures.  For 73 of the 105 claims sampled, the initial request for medical records was sent to the provider 9 to 20 days later than required and followup requests for missing medical records were sent 1 to 204 days later than required.  Also, quality assurance reviews were not performed for 22 of the 45 claims sampled, and the results of those reviews that were performed were not shared with medical review specialists.