Medicare Compliance & Reimbursement

Plus: Keep medication units in check with MAC-approved drug calculator tool.

Each year, CMS releases its Comprehensive Error Rate Testing (CERT) results, outlining areas where Medicare may have made improper payments. But now it appears that the CERT results themselves may be riddled with errors.

The OIG conducted a review of the 2008 CERT results and found that the actual error rate was more than double what CMS's CERT contractor actually found.

In some cases, the difference in error rates was due to "professional judgement" regarding how the auditor interpreted the medical documentation, but in other instances, CMS's original CERT contractor agreed that it had missed certain errors in medical documentation.

To read the complete OIG report, visit www.oig.hhs.gov/oas/reports/region1/10900511.pdf.

• When Part B MACs publish the top errors that they see in claims submitted by physicians, incorrectlybilled drugs are always near the top of the list. If you're one of the coders that has trouble assigning units to drug claims, one MAC has a solution for you. Palmetto GBA, a Part B payer, now offers a "Drug Lookup and Calculator Tool," which was created "to help providers submit the correct number of units on their claims by calculating and converting the dosage administered to the patient."

Plus: The calculator displays the current maximum allowable units assigned to the drug. For instance, if you enter J2920 (Injection methylprednisolone sodium succinate) into the system, it will ask you how many milligrams you administered. The system will then tell you how many units to report, with a notation that 83 units are the maximum allowed for this drug.

To access the tool, go online to www.palmettogba.com/palmetto/Mc.nsf/IVR_Display?OpenForm.

• Despite heightened focus on how to stay compliant with the Stark law, some medical practitioners are still getting nabbed for infractions. On Oct. 5, the OIG entered into a settlement agreement with a California hospital director who paid $64,000 to resolve allegations that he violated the Civil Monetary Penalties Law and the Stark law, which prohibits self-referral.

The hospital director, who also served as the compliance officer, allegedly "personally negotiated financial arrangements with physicians and directed improper pay-ments to them," according to an Oct. 5 OIG press release.

In addition, the OIG also accused the hospital director of causing "submission of false claims to the Medicare program that should not have been paid based upon the Stark Law violation."

To read the OIG's press release on the subject, visit www.oig.hhs.gov/publications/docs/press/2009/BasktCMPNewsRelease508.pdf.

• If your Medicare Secondary Payer claims appear to be in limbo, you're not alone. National Government Services (NGS), a Medicare payer in 20 states, noted an "increase in Medicare Secondary Payer (MSP) claim suspense," the MAC noted on its Web site on Sept. 29.

"This increase is the result of two FISS/Data Center issues that were first reported on September 10," NGS indicated. "All Medicare contractors have been advised to hold the claims that are affected by this issue. The Centers for Medicare & Medicaid Services (CMS) has indicated that they are aware of the high volume of claims suspended nationwide and are working toward a solution."

The claims should still finalize within the 30-day allowable claims processing timeline, NGS indicated. Visit www.ngsmedicare.com  for more information on this issue.

Once agencies begin using the OASIS C data set, outcome reports and Home Health Compare will necessarily change, the Centers for Medicare & Medicaid Services confirms. Some of the OASIS measures will be the same, some will be deleted, and others will be added, CMS said in a question and answer reported by the National Association for Home Care & Hospice.

The change in items between OASIS B-1 and OASIS C means CMS will need to produce new reports based on data from OASIS C, once enough is available, the agency said.

New way: CMS plans to use three sets of reports under OASIS C.

1. Process measure reports -- which do not require risk adjustment -- will present measures based on the new process of care items on OASIS C. The first CASPER reports presenting data on all the process measures will be based on the data from January 2010 through June 2010.

2. Risk-adjusted outcomes reports will present outcome measures based on the OASIS C items and will be risk adjusted using new models developed using the OASIS C items. The first preview report of risk-adjusted OASIS C outcomes will be based on data from January 2010 through December 2010.

3. Potentially avoidable events reports (formerly adverse events) will present data on adverse events based on OASIS C. CMS has not yet decided whether to develop risk-adjustment models for these measures.

Heads up: Look for descriptions of the revised quality measures and drafts of the revised report formats on CMS' Web site by the end of September, the agency announced in its answer.