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Comprehensive Error Rate Testing (CERT)
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Error rate: DME tips the scales
From HME News 02.19.2010

BALTIMORE - The DME MAC error rate for FY 2009 was 51.9%, according to a Comprehensive Error Rate Testing (CERT) report released earlier this month by CMS.

The DME MAC error rate was higher than other types of contractors largely due to changes CMS made to its review process in 2009. Rather than allowing for clinical review judgment based on billing history and other available information, it required medical reviewers to follow the documentation requirements outlined in Medicare regulation, statute and policy.

"CMS's stricter adherence to policies disproportionally affected DME claims," the report states. "Once CMS clarified that clinical review judgment may not override documentation requirements, more errors were found on DME items."

The error rate for all Medicare fee-for-service: 7.8%. Error categories include no documentation, insufficient documentation, medically unnecessary service and incorrect coding.

The report alludes to the difficulty of obtaining appropriate documentation for DME, something industry stakeholders like AAHomecare have lamented to CMS for years.

"It is often more difficult for DME contractors to obtain the proper documentation because they request documentation from the supplier who billed for the item, not the medical professional who ordered the item," the report states. "The supplier then is responsible for submitting documentation to CMS that they have collected from the ordering provider. The involvement of multiple parties can cause a delay in documentation receipt and incomplete documentation."

In a bulletin to members last week, AAHomecare pointed out: "While a large error rate may appear troubling to policymakers, CMS notes (in the report) that 'The CERT program cannot be considered a measure of fraud.'"

To read the full report, go to: https://www.cms.hhs.gov/apps/er_report/edit_report_1.asp?from=public&reportID=15


 

From AAHomecare February 17, 2010

New Report on Medicare Error Rates Notes HMEs’ Difficulty Collecting Documentation from Physicians
The new Comprehensive Error Rate Testing (CERT) report for 2009, released by the Centers for Medicare and Medicaid Services (CMS), acknowledges for the first time the difficulty that HME providers face when trying to collect proper documentation from physicians.

The CERT report projects an error rate of 51.9 percent for HME in 2009. While a large error rate may appear troubling to policymakers, CMS notes that “the error rate is not a measure of fraud.”

AAHomecare has consistently told CMS not to equate improper payments with fraud, and a number of AAHomecare’s comments have been reflected in the report.

CMS points out that the higher error rate for HME was “based on stricter adherence to policies that disproportionately affected HME claims. More DME claims were determined to be paid in error because of the more strict enforcement of documentation requirements rather than allowing for clinical review judgment. In the past, reviewers applied clinical review judgment to claims to fill in the gaps of knowledge where documentation was missing. Once CMS clarified that clinical review judgment may not override documentation requirements, more errors were found on HME items.”

“The AAHomecare Regulatory Council has pointed out these critical details and context to CMS in many in-person meetings with CMS staff,” said Walter Gorski, vice president of government affairs for AAHomecare. “We are pleased that the agency is willing to listen and engage the association on these critical issues.”

CMS also stated that “it is often more difficult for DME contractors to obtain the proper documentation because they (contractors) requested documentation from the supplier who billed for the item, not the medical professional who ordered the item. The supplier is then responsible for submitting documentation to CMS that they have collected from the ordering provider. The involvement of multiple parties can cause a delay in documentation receipt and incomplete documentation.”

This is the first public comment from CMS that acknowledges the difficulty that HME providers face when trying to collect proper documentation from physicians.

Gorski added, “AAHomecare is now pursuing activities with CMS aimed at reducing this error rate. However, the heart of the problem is the complexity of the documentation for various segments of HME items and services. One way to view the report is that federal regulators are questioning and overturning physicians’ judgment more than 50 percent of the time. This is an indictment of the system. Therefore, AAHomecare is focusing attention on ways to streamline the program and reduce the hassle factor for HME providers.”

AAHomecare staff is currently reviewing the report and the communications and government relations team will respond accordingly. Click here to view the report.



 
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