Review of Corrective Actions To Improve the Comprehensive Error Rate Testing Process for Obtaining Medical Records

EXECUTIVE SUMMARY:

During Fiscal Year 2003 the Centers for Medicare and Medicaid Services (CMS) experienced a significant problem with providers that did not respond to requests for medical records for use in developing the Medicare payment error rate.  The objective of this review was to evaluate the adequacy of CMS's corrective actions to improve the process for obtaining medical records.  The CMS has implemented a number of corrective actions to improve this process.  Based on our review of data for the first three quarters of the fiscal year 2004 error rate sample, these corrective actions appear to have increased provider responsiveness to requests for medical records.  However, as of April 8, 2004, providers had still failed to submit medical records supporting 2,239 of the 126,618 claims in the fiscal year 2004 sample, despite repeated requests for the records.  Therefore, we have initiated an indepth review to determine why providers failed to respond.  Additionally, as part of our broader evaluation of the program, we will further assess the impact of CMS's corrective actions.