OIG: CMS missing accurate Medicare error data

The Centers for Medicare & Medicaid Services should include appeals decisions from the Comprehensive Error Rate Testing (CERT) program when it calculates reported errors, the Office of Inspector General said a recent report. OIG recommended CMS use a reliable methodology for adjusting the national Medicare fee-for-service error rate.

An error is the difference between the amount that Medicare pays to a provider and the amount that it should have paid. CMS submits that information to Congress each year under the Improper Payments Information Act of 2002. Although providers have the right to appeal payment denials, those decisions made after the cutoff period aren't included in report estimates, the OIG said, thereby resulting in some misrepresented data.

In its review of the appeals process, OIG found that if CMS included CERT claim payment denials that were overturned after the cutoff date, it would have decreased the reported error rate from 7.8 percent to the actual 7.2 percent for 2009 and from 10.5 percent to 9.9 percent for 2010.

"If CMS had included these overturned CERT claim payment denials in its error rate calculations, it would have decreased the estimated value of reported errors for FYs 2009 and 2010 by approximately $2 billion each year," OIG said. "CMS could improve the accuracy of the reported estimate of improper payment error rates by including an adjustment for overturned CERT claim payment denials."

For more information:
- check out the OIG summary
- here's the OIG report (.pdf)

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