CERT Overpayment Report - Documentation is the Key

Gloryanne Bryant, RHIA, CDIP, CCS, CCDS HHS 1 Comment

CERT Overpayment Report - Documentation is the Key

The 2021 Comprehensive Error Rate Testing (CERT) report contains statistics on improper payment made by the Medicare program to providers and is published annually. The CERT data is supported by a sample of Medicare Fee-For-Service (FFS) claims that were reviewed by an independent medical review contractor to determine if they were paid properly under Medicare coverage, coding, and billing rules. Information in the CERT report can help providers be proactive with their compliance reviews and audits. 

Dating back to 1996 is when the Medicare Fee-for-Services (FFS) improper payment rate was first measured. It was the Health and Human Services Office (HHS) Inspector General (OIG) who was responsible for estimating the improper payment reporting from 1996 - 2002. Then in 2003, CMS began to produce a large sample size of claims for determining the improper payment rate. 

It is known that the fiscal year (FY) for Medicare, it is from October 1 to September 30, however, the Medicare FFS sampling period does not correspond with the FY due to practical constraints with claims review and rate calculation methodologies. Thus, the FY 2021 Medicare FFS improper payment rate included claims submitted during the 12-month period from July 1, 2019, through June 30, 2020. 

When we think about payment errors of course it is the “money” about which we are talking. According to the 2021 CERT report, the total amount of dollars paid by the Medicare program were $374.74 billion and of that $25.03 billion dollars were identified to be paid in error. Although that 25 billion is roughly 6.2% of the total paid, it is still a lot of money paid in error (think taxpayer dollars and risk). 

The CERT report has data from Medicare Part A&B claims. This includes: 

  • Hospitals 
  • Skilled nursing facilities 
  • Home health and hospice providers
  • Renal dialysis facilities
  • Comprehensive outpatient rehabilitation facilities
  • Rural health clinics
  • Federally qualified health centers 

Some highlights of the 2021 CERT overpayment report indicate that errors are classified into the following categories and with the following error percentages: 

  • Insufficient Documentation = 64.1%
  • Medical Necessity = 13.6%
  • Incorrect Coding = 10.6%
  • Other = 6.9%
  • No Documentation = 4.8% 

Another interesting statistic found in the report was the Hospital Outpatient (includes Hospital Outpatient Prospective Payment System (OPPS), Laboratory, and Others) area error rate which was higher than Skilled Nursing, Home Health and Hospice. The root cause of the Hospital Outpatient errors was listed as follows (you’ll see a pattern regarding “insufficient documentation”): 

  • Provider’s intent to order (for certain services) = Missing Insufficient Documentation  
  • Order = Missing Insufficient Documentation 
  • Order = Inadequate Insufficient Documentation 
  • Documentation to support medical necessity = Missing Insufficient Documentation 
  • Lab panel billed is not the service ordered = Incorrect Coding  
  • Documentation for the associated diagnostic lab test(s) = Inadequate Insufficient Documentation  
  • Documentation for the billed date of service = Missing Insufficient Documentation  
  • Physical/Occupational/Speech Therapy Certification/Recertification = Missing Insufficient Documentation  
  • Documentation to support the services were provided or other documentation required for payment of the code = Missing Insufficient Documentation  
  • NCD requirement(s), other documentation required for payment = Missing Insufficient Documentation  

The frequency of documentation issues (errors) is really a call out to Clinical Documentation Improvement and Coding querying for documentation clarification in all settings. This also speaks to the need for provider education and to continued auditing practices. In addition, we need to look closely at having concurrent checks and balances in place in addition to prebill and retrospective reviews for completeness and accuracy. 

The current CERT Review Contractor is NCI Information Systems, Inc. and the CERT Statistical Contractor is the Lewin Group, Inc. You can access the 2021 CERT report at: https://www.cms.gov/files/document/2021-medicare-fee-service-supplemental-improper-payment-data.pdf-0 

In addition, as part of your compliance auditing you must have a “rebilling” or repayment process in place for overpayments. Per the Affordable Care Act (ACA) and CMS: 

Section 1128J(d)(2) of the Act requires that an overpayment be reported and returned by the later of: (A) the date which is 60 days after the date on which the overpayment was identified; or (B) the date any corresponding cost report is due, if applicable. Section 1128J(d)(3) of the Act specifies that any overpayment retained by a person after the deadline for reporting and returning an overpayment is an obligation (as defined in 31 U.S.C. 3729(b)(3)) for purposes of 31 U.S.C. 3729. In the February 16, 2012, Federal Register (77 FR 9179). 

Visit the following for more information: https://www.cms.gov/newsroom/fact-sheets/medicare-reporting-and-returning-self-identified-overpayments 

This CERT report provides some great data to help providers take a look at themselves and their practices in a proactive manner, so take this report to your compliance and revenue cycle leaders so action can be taken. 

MRA is available to provide assistance in consulting as well as for auditing and education.

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