Former CERT Supervisor: Better Process 'Gets Error Off the Books'

In its recent report on 2019 Medicare fee-for-service improper payments, CMS attributed more than half of them to insufficient provider and supplier documentation. That conjures images of unsigned physician orders and flawed certifications, but often Medicare auditors never received the documentation, or their requests didn’t reach the right desk at the hospital.

“Sometimes it’s not the substance, it’s the process,” said Ian Mattis, former supervisor of the Comprehensive Error Rate Testing (CERT) program at Novitas Solutions, a Medicare administrative contractor (MAC). When the MAC connects with the right person and gets its hands on documentation, it “gets the error off the books,” he said. “It reduces the error rate and helps the CERT, because then we don’t have to process it for a refund.”

CMS has instructed the MACs to give hospitals multiple chances to submit documentation after they receive the additional documentation request (ADR) from the CERT review contractor, and hospitals may be reminded five times to send the documentation. But this is still apparently a problem based on the findings in the 2019 improper payments report,[1] because the CERT contractor considers claims in error when providers fail to produce documentation. CMS said 59.5% of the improper payments were attributed to insufficient documentation. They are defined as missing/inadequate orders; missing/inadequate plan of care; missing/inadequate records; inconsistent records (e.g., date, provider, service, beneficiary); and certification/recertification requirements not met.

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