Results of Limited Scope Review at Tri-Town Economic Opportunity Committee

摘要

The Centers for Medicare & Medicaid Services (CMS) established the Comprehensive Error Rate Testing (CERT) program to produce a Medicare fee-for-service error rate. An error, or improper payment, is the difference between the amount that Medicare paid to a health care provider and the amount that it should have paid. Using the results of the CERT program, CMS annually submits to Congress an estimate of the amount of improper payments for Medicare fee-for-service claims pursuant to the Improper Payments Information Act of 2002 (P.L. No. 107-300). As part of the Medicare error rate process for fiscal year (FY) 2009, CMSs CERT contractor conducted medical record reviews of a random sample of paid claims from all types of providers. The sample consisted of 99,480 claims valued at about $71 million. The CERT contractor found that 19,754 sampled claims resulted in improper payments valued at about $4.7 million. Based on these sample results, the national paid claim error rate for FY 2009 was 7.8 percent ($24.1 billion), a significant increase over the FY 2008 error rate of 3.6 percent ($10.4 billion). According to CMSs FY 2009 Improper Medicare Fee-for-Service Payments Report, the increase in the error rate was attributable to substantial changes in the CERT medical record review methodologies. Our objective was to analyze the types of providers that caused the majority of FY 2009 improper payments and the most significant types of payment errors made by these providers.