Medicare payment error rate increases. The Centers for Medicare & Medicaid Services Dec. 13 unveiled the Medicare error rate - alongside a promise to breathe down your contractor's neck until the rate improves.
In fiscal year 2004, the error rate for fee-for-service claims was 9.3 percent, compared to last year's adjusted rate of 5.8 percent. FY 2003's unadjusted error rate, which includes non-responses, was 9.8 percent.
The majority of this year's errors were due to insufficient documentation. Other problems included non-responses to requests for medical records, medically unnecessary services and incorrect coding.
But CMS says new "detailed performance monitoring" of individual Medicare contractors will more accurately measure error rates in Medicare payments - and slash that rate down to 4 percent in four years. Durable medical equipment regional carriers had an error rate of 11.1 percent while fiscal intermediaries' rate was 15.8 percent.
Among DMERCs, Palmetto GBA (Region C) had the worst error rate at 14 percent while Adminastar Federal (Region B) fared the best with 6.6 percent. CMS did not separate out error rates for regional home health intermediaries.
Redoubled compliance efforts will likely mean more attention to your claims this fiscal year.
To improve error rate medical review responses, CMS notes it has extended the timeframe from 55 to 90 days (see Eli's HCW, Vol. XIII, No. 39, p. 309). In 2005, it will try other solutions like accepting electronic records in small tests and more education.
The 2004 error rate short report is at
www.cms.hhs.gov/CERT. Your patient base could make judicial penalties that much harsher. One DME company owner recently learned that the hard way, when she had no luck appealing an upgraded 10-year prison sentence.
Jacqueline O. Richardson was sentenced last year for illegally receiving $385,000 from Medicaid for nonexistent business transactions. In a recent appeal, Richardson argued that the sentencing did not apply because the offense involved a large number of victims - and she did not know they were "vulnerable." Under sentencing rules, jail time can increase by two levels for offenses against "vulnerable victims."
The U.S. Fifth Circuit Court of Appeals affirmed the 10-year sentence, and reminded that sentencing guidelines provide a four-level increase for offenses involving 50 or more victims, according to its Dec. 6 decision (No. 03-51000). "Richardson knew that the victims, most of whom were over the age of 65 and physically disabled, were vulnerable," the decision reads.
Prosecutors charged Richardson's original scheme was promising patients supplies that were never delivered, not appropriate or were substandard, according to Texas Attorney General Greg Abbott. CMS apparently won't be losing its head honcho after all. In a surprise move, President Bush has nominated Environmental Protection Agency chief Mike Leavitt as Secretary of the Department of Health and Human [...]
