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Fraud & Abuse:

Will Your State’s Error Rate Land You On Medicare’s ‘Most Wanted’ List For Medical Review?

Published on Fri Jan 05, 2024

Meet your CERT contractor before it’s too late.

Where your state falls on Medicare’s payment error rate ranking may determine what oversight initiatives you see come to your doorstep.

For example: The Centers for Medicare & Medicaid Services’ new 2023 Medicare Fee-for-Service Supplemental Improper Payment Data report includes Medicare's overall payment error rate (see HHHW by AAPC, Vol. XXXII, No. 1) as well as a partial list of home health and hospice projected improper payments, combined, by state. At the top of the list is Oklahoma, with whopping 24.7 percent improper rate.

That figure “is nearly four times higher than the average for all states at 6.3 percent, and more than double the next highest rate of 10.1 percent for California,” points out reimbursement expert M. Aaron Little with FORVIS in Springfield, Mo. That makes it “less difficult to understand the CMS decision to implement [the Review Choice Demonstration] for home health providers in Oklahoma,” Little notes.

These 5 States Top The List

CMS launched RCD in Oklahoma last month (see HHHW by AAPC, Vol. XXXII, No. 32). And while CMS has remained tight-lipped on the prospect, experts predict it will roll out an RCD expansion — perhaps even nationwide — rather than end the program later this year as scheduled.

However, pulling into the top payment error rate spot doesn’t land Oklahoma in the top spot for total projected overpayments. See the report’s list of the states with the top five home health and hospice payment error rates listed to find out which state achieved that dubious distinction:

1. Oklahoma, 24.7 percent error rate representing $132.7 million — 0.4 percent of Medicare’s overall improper payments. Total claims reviewed: 76.

2. California, 10.1 percent at $612.0 million — 1.9 percent of Medicare’s overall improper payments. Total claims reviewed: 262.

3. New Jersey, 9.3 percent at $88.1 million — 0.3 percent of Medicare’s overall improper payments. Total claims reviewed: 37.

4. Texas, 8.4 percent at $339.5 million — 1.1 percent of Medicare’s overall improper payments. Total claims reviewed: 377.

5. Florida, 7.1 percent at $273.8 million — 0.9 percent of Medicare’s overall improper payments. Total claims reviewed: 157.

Plus: A state that didn’t even make the top five for improper payment rate did rank up there for percentage of Medicare’s overall improper payment. Ohio had a relatively lower 5.8 percent error rate, but racked up $119.8 million in improper payments with 0.4 percent of the Medicare’s overall improper payments. It had 90 claims reviewed.

While the list includes only 17 states and territories, it does highlight states with low error rates too: Pennsylvania at 0.2 percent and Virginia at 0.3 percent.

CMS takes pains on its Comprehensive Error Rate Testing webpage to point out that “the improper payment rate is not a ‘fraud rate,’ but is a measurement of payments that did not meet Medicare requirements.” However, CERT stats can clearly point to problems that Medicare may want to investigate with more intense scrutiny.

Increase Your RAC Know-How This Year

If you’d like to help keep your state out of “most wanted” territory, becoming familiar with the Comprehensive Error Rate Testing program is a good idea.

“The CERT contractor randomly selects claims providers submit to Medicare to determine if the claim was paid properly under Medicare coverage, coding and billing rules by requesting medical records,” explains HHH Medicare Administrative Contractor National Government Services in a recent post to its website. “If the medical records do not support that the rules were met, the claim is counted as either a total or partial improper payment and a CERT error is assigned,” NGS details.

The current CERT Review Contractor and CERT Documentation Contractor is Empower AI Inc., which is also a Program Safeguard Contractor (PSC), MAC Noridian says on its website. AI Inc., based in Reston, Va., was formerly known as NCI Information Systems Inc., CMS says on its website.

The Lewin Group Inc. is CMS’s CERT Statistical Contractor.

NGS points providers to a two-minute CMS video on how your MAC can help you with CERT review. “Your MAC wants to help you succeed in the CERT program,” CMS says in the video.

Tip: “When you have questions about CERT reviews, call your MAC’s provider contact center. They are there to help you with your CERT-related claims,” the CMS speaker advises. “In fact, if you call the CERT contractor, it will redirect you to your MAC,” she says.

Note: State data is adapted from Table B11 at www.cms.gov/files/document/2023medicarefee-servicesupplementalimproperpaymentdatapdf.pdf. See the CERT video at https://youtu.be/mdnfuzr7yyE?si=qh61-xI3lTxKPfph.

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