CMS resumed the Comprehensive Error Rate Testing (CERT) program that establishes whether claims paid by Part A/B Medicare Administrative Contractors (MACs) and Durable Medical Equipment MACs (DME MACs) are paid correctly each year. The CERT program resumed reviewing claims submitted from July 1st, 2019 through June 30, 2021. The program releases data on improper payment in the Medicare Fee-for-Service (FFS) program on a national scale. CMS considers the improper payment rate as being the “measurement of payments that did not meet Medicare requirements.”
After evaluation by an independent medical review contractor, MACs and DME MACs claims may be recouped or reimbursed depending on if certain criteria are met, such as if they were paid properly under Medicare FFS coverage, coding, and billing rules. The CERT Documentation Contractors request that providers submit additional documentation to support the claims. According to the data that CERT collected for 2020 claims, improper payment for claims can be as high as 63.1% because of “insufficient” documentation. In more concrete terms, this accounts for a loss of up to $14,573.18M on an annual basis for MACs and DME MACs. And this is not just for one category or a few complex codes. For items as simple as surgical dressing, the improper coding rate can be as high as 65.7%, with claims such as diabetic shoes being 68.2%, glucose monitors being 34.2%, and even oxygen supplies/equipment and enteral nutrition being 26.3% and 39.3% respectively.
The CERT Documentation Contractors request that providers submit additional documentation to support the claims. Failure to submit the correct documentation for the claim in time may cost the account the chance for appropriate payment on a significant scale. For example, although the overall improper payment rate for claims submitted in 2020 was 6.27%, the improper payment rate for Durable Medical Equipment, Prosthetics, Orthotics, and Supplies for claims submitted in 2020 amounted to 31.80% or to be more specific, $2.77 billion.
Why does this matter? Because throughout 2022, the CERT Documentation Contractors will be continuing to send documentation requests that must be submitted in a 45-day window of the request to receive recoupment or reimbursement for claims improperly submitted previously. This hurdle for correct documentation can be overcome with an accomplished team to support your accounts with Billing Guides and a medical technology hotline that can assist with documentation and claims submission to avoid audits and denials.
Have your accounts received a request for documentation from your region’s CERT Contractor for claims submitted from July 1st, 2019? Not sure where to begin or what next steps may be? Let GIRS give you the guidance (and turnaround time) to help the provider submit the documentation requested. We also have successfully assisted our clients with overturning claims denials.
For more information, email us at info@girsinc.com or call us at 901-834-9119.
Disclaimer: The information in this blog is based on payer information which is dynamic. It is accurate at the time of posting but should not be construed to be reimbursement or legal advice. CPT® is the trademark of the American Medical Association (AMA).
Sources:
- Comprehensive Error Rate Testing (CERT) | CMS
- Improper Payment Rates and Additional Data | CMS
- Background | CMS
- Information for Providers | CMS
- 2020_Medicare Fee-for-Service_Supplemental_Improper_Payment_Data (cms.gov)
About GIRS
For more than 19 years, GIRS has been assisting medical technology manufacturers with their market uptake and reimbursement strategies so that patients can have access to the care that they need. To implement successful market access strategies, the GIRS Value Discovery Landscape Assessments® team and the Payer Advocacy Compass® team work together to develop and implement foundation reimbursement landscape and payer advocacy strategies to obtain positive coverage, appropriate payment, and innovative payer contracting arrangements to improve market uptake. For more information, email us at info@girsinc.com or call us at 901-834-9119.