On July 15, 2010, the OIG released the results from their “Analysis of Errors Identified in the Fiscal Year 2009 Comprehensive Error Rate Testing Program”. The objective of the OIG in performing this review was to identify which providers caused most of the improper payments and the types of payment errors that were made. Out of 99,480 sampled claims for FY 2009 (representing $71 million), nearly 20,000 claims resulted in improper payments totaling $4.7 million. The national paid claims error rate based on these results is 7.8% or $24.1 billion. Six provider types topped the list accounting for 94% ($4.4 million) of the $4.7 million in improper payments and are as follows:
- Inpatient hospitals
- DME suppliers
- Hospital outpatient departments
- Physicians
- Skilled Nursing Facilities
- Home Health Agencies
The majority (98%) of payment error types fell in the following three categories:
- Insufficient documentation (missing clinical notes, missing test results, and incomplete/missing/illegible physician orders)
- Miscoded claims (diagnosis or procedure)
- Medically unnecessary services
Part of the review focused on medical necessity of inpatient stays versus observation which is consistent with one of the areas in which the OIG and RACs are focusing. Providers should REALLY focus on their case management and admission protocols to decrease error rates and avoid costly investigations and potential recoupments.
The report outlines errors and gives examples specific for each provider type. Additionally, we encourage providers to take a detailed look at the report to identify areas that may need further evaluation in their own practice.
The OIG recommended to CMS that they use the results of CERT reports to identify areas of potential program weakness based on the types of errors that were identified in the analysis, make corrections, and take any steps needed to strengthen the CERT program. CMS agreed and will share these results with each of the contractors.
To view the entire report, go to: http://www.oig.hhs.gov/oas/reports/region1/11001000.pdf
