Oversight and Evaluation of the Fiscal Year 2006 Comprehensive Error Rate Testing Program

EXECUTIVE SUMMARY:

The objectives of our fiscal year (FY) 2006 Comprehensive Error Rate Testing (CERT) audit were to determine: (1) whether CMS ensured that its two CERT contractors had appropriate controls to ensure that medical and quality assurance reviews and initial and follow-up document requests followed established procedures and operated effectively; (2) the status of initiatives to reduce the CERT error rate that CMS identified in its November 2005 "Improper Fee-For-Service Payments Long Report," and (3) whether CMS took appropriate action on recommendations made in our FY 2005 audit report.

CMS ensured that AdvanceMed had appropriate controls to ensure that medical and quality assurance reviews were in accordance with established procedures and that it adequately maintained, updated, and reported the results of those reviews. CMS also ensured that Livanta had appropriate controls to ensure that medical documentation was properly received, controlled, and provided to AdvanceMed and that Livanta followed up with providers when medical records were not received promptly. In addition, CMS advised us that it had performed several tasks to accomplish its initiatives to reduce the CERT error rate. Finally, CMS and its CERT contractors took appropriate action on the recommendations made in our FY 2005 audit report.