Home Health & Hospice Week

You’re on the hook for securing documentation from other providers, MAC stresses.

One HHH Medicare Administrative Contractor isn’t happy with how providers are failing to reply to important record requests.

“CGS has identified an increase in the number of Comprehensive Error Rate Testing (CERT) reviews that receive No Documentation errors,” the MAC reports in a Jan. 30 post on its website. “The CERT Review Contractor assigns the No Documentation error category (error code 16) to claims when the provider or supplier fails to respond to repeated requests for medical records [or] responds that they don’t have the requested documentation,” CGS elaborates.

Why it’s important: “The Centers for Medicare & Medicaid Services (CMS) estimates the Medicare Fee-for- Service (FFS) program improper payment rate through the Comprehensive Error Rate Testing (CERT) program,” CGS explains on its CERT webpage. “Each year, the CERT program reviews a statistically valid stratified random sample of Medicare FFS claims to determine if they were paid properly under Medicare coverage, coding, and payment rules.”

CERT Serves As MAC Report Card

What the MAC doesn’t come out and say, is that it makes CMS and the MACs look bad if the CERT Contractor finds a high error rate for claims. (The current CERT Review Contractor and CERT Documentation Contractor is Empower AI Inc.)

“The CERT program is designed to determine if Medicare contractors are processing and paying claims correctly,” HHH MAC National Government Services notes in online guidance.

In figures released last month, both the home health and hospice error rate figures dropped significantly in the most recent year, to 7.7 percent and 5.4 percent, respectively (see more details in HHHW by AAPC, Vol. XXXIII, No. 1). And Medicare and its contractors undoubtedly would like them to stay low.

CGS offers these tips to beat No Documentation errors:

• “Provide ALL pertinent medical records/documentation and any additional documentation to support the specified claim,” the MAC requests.
• “The provider that billed the claim is responsible for maintaining all documentation necessary to support the services billed on the claim,” CGS reminds. “In some cases, you may need to obtain records from a different provider (e.g., referring/ordering provider or rendering provider/facility) and/ or for dates prior to and/or after the billed date of service,” the contractor instructs
• “When you send documentation, always include the barcoded cover sheet as the first page. This allows the CERT Documentation Contractor to identify the correct beneficiary/ date(s) of service to which the documentation applies,” the MAC directs.

CERT Info May Shape TPE

Remember: CMS uses the collected CERT data in a variety of ways, including to “monitor and report the accuracy of Medicare Fee-for-Service (FFS) payments,” explains HHH MAC Palmetto GBA says in online guidance. The agency also utilizes the CERT auditors’ results to “protect the Medicare Trust Fund by identifying errors and assessing error rates, at both the national and regional levels,” CGS indicates.

Additionally, the feds track error trends, looking at claims anomalies among certain provider types, codes, and services through the CERT program. These findings help CMS pinpoint perennial problem areas that cause the improper payment rate to surge upwards annually, costing taxpayers billions. The agency then uses this critical information to rein in outliers, rectify issues, and promote program integrity, CGS suggests.

Plus, MACs use the CERT information to better determine regional programming and education for providers, including tools like the Targeted Probe & Educate (TPE) program and Comparative Billing Reports (CBRs) in a specific jurisdiction.

Note: The CGS notice is at www.cgsmedicare.com/parta/ pubs/news/2024/01/cope150254.html. The CERT website is at https://c3hub.certrc.cms.gov.