Oversight and Evaluation of the Fiscal Year 2005 Comprehensive Error Rate Testing Program

EXECUTIVE SUMMARY:

Our objectives were to determine whether:  (1) CMS and AdvanceMed had appropriate controls to ensure that AdvanceMed followed established procedures in making medical review decisions and adequately maintained, updated, and reported the results of those reviews; (2) CMS and AdvanceMed had implemented a prior recommendation to complete the Comprehensive Error Rate Testing (CERT) quality assurance program; and (3) CMS had ensured consistency and coordination of the error rate programs.  CMS and AdvanceMed generally had appropriate controls to ensure that AdvanceMed followed procedures and adequately maintained, updated, and reported results.  CMS could do more to ensure consistency and coordination of the error rate programs.  Sampling periods were not consistent, and management of the programs was decentralized. 

We recommended that CMS:  (1) work to establish CERT and Hospital Payment Monitoring Program sample periods that are more consistent with each other and more closely aligned with the fiscal year and (2) consider centralizing the management of the error rate programs under a single office.  CMS concurred with the findings and recommendations.