News: CERT report shows an improper payment rate of 9.5%

Medicare fee-for-service claims had a 90.5% accuracy rate and a 9.5% improper payment rate for all claims submitted between July 1, 2015-June 30, 2016, according to a recent CMS Comprehensive Error Rate Testing (CERT) report.

Insufficient documentation accounted for 64.1% of improper payments for both Part A and Part B claims, JustCoding reported. The report also cited missing documentation (1.7%), incorrect coding (13.1%), medical necessity (17.5%), and other causes (3.6%) as the root behind the improper payment rates.

In an analysis of the causes for insufficient documentation in Part B claims, CMS determined the following:

• 36.8% of insufficient documentation on physician claims was due to multiple universal errors
• 35.4% was due to missing or inadequate records
• 19.9% was due to inconsistent records
• 6% was due to missing or inadequate orders
• 0.7% was due to missing or inadequate plans of care

CMS also analyzed improper payments by type of service for Part B claims. Laboratory tests topped the list for Part B services with the highest improper payment rates, according to JustCoding. The report projected that over a billion dollars in laboratory payments were paid improperly, mainly due to insufficient documentation.

Established office visits, hospital visits, and ambulatory services also had strikingly high improper payment rates, with improper payments for each service type approaching the billions.

According to the report, E/M codes with the highest improper payment rates. Code 99239 for hospital discharge day management had the highest improper payment rate (5.2%) due to incorrect coding.

Information from the report was used to supplement improper payment information in the annual Department of Health and Human Services Agency Financial Report, JustCoding reported. For more information on improper payments and other challenges affecting healthcare, read the full financial report.

Editor’s note: This article originally appeared in JustCoding. To read CMS’ report on the CERT findings, click here. To read about how CDI professionals can use the CERT (and other) reports in audit defense, click here.