Medical Review:
Respond To CERT Requests Or Face Denials
Published on Thu Oct 21, 2004
Error rate contractor may refer you to the OIG if you ignore its letters. The Centers for Medicare & Medicaid Services has improved its payment error rate calculations - by using some strong-arm tactics on providers.
CMS took over the Medicare comprehensive error rate testing (CERT) program from the HHS Office of Inspector General in 2003, and providers' responses to CERT medical review record requests dropped off considerably that year, the OIG notes in a recent report.
But provider responses have rebounded in 2004, the OIG reveals. The 8 percent non-response rate to CERT record requests in 2003 dropped to 1 percent in 2004.
One chief reason for the better response rate: a threat to refer providers to the OIG if they don't comply. Another good reason: automatic denial of the claim when providers don't submit requested supporting documentation.
CERT contractor AdvanceMed chooses about 28,000 claims per year for review to see whether providers are billing (and Medicare contractors are paying) correctly, explained Wayne Steiner, CERT coordinator for Part B carrier HGSAdministrators in Pennsylvania. If AdvanceMed decides your claim lacks evidence of medical necessity, it sends the claim to your intermediary or carrier to deny and recoup the money, Steiner said in a Health Care Compliance Association teleconference on the CERT program this summer.
In 2003, many providers didn't respond to CERT requests because they didn't recognize Advance-Med or the CERT program, Steiner noted. Advance-Med was formerly known as DynCorp. And the CERT request letters didn't have the CMS logo on them, so providers dismissed them, Steiner said.
Providers also were worried that under HIPAA, they weren't allowed to disclose the patient records to AdvanceMed, Steiner added.
Some providers tried to fax in their medical records, but AdvanceMed had only one fax machine to receive records, the OIG notes in its report. So providers had thought they responded, but AdvanceMed never received the fax.
Now CERT request letters clearly show the program is run by CMS and explicitly state that under HIPAA, providers can submit documentation with no beneficiary authorizations required.
Medicare contractors have been educating providers about the CERT program, and earlier this year CMS posted a MedLearn Matters article directing providers to submit records.
AdvanceMed has added three more fax machines to handle the heavy faxing load, the OIG report notes.
And the CERT contractor now sends a total of four letters requesting records for a claim if providers are at first non-responsive, and providers' contractors contact them by phone three times. Some providers complained they were hassled for records by followup letters and calls mere days after receiving the first request (see Eli's HCW, Vol. XIII, No. 14, p. 111).
But providers now have more time to respond to the letters - the deadline changed from 45 to 90 [...]
