Thursday, May 21, 2009

WASHINGTON--A new audit report from the Department of Health and Human Services’ Office of Inspector General throws into question the accuracy of the 2008 DME error rate claimed by the Centers for Medicare and Medicaid Services.
 
According to the new OIG report, a review of 250 sampled claims showed 175 to be in error—far beyond the 23 errors claimed by the contractor that conducts comprehensive error rate testing for CMS.
 
Palmetto GBA, which conducted the review, said the majority of the claims lacked sufficient documentation of medical necessity. The CERT contractor agreed with Palmetto’s assessment of only 17 of those claims, in addition to the original 23.
 
The OIG, however, said that the results of the review cast a shadow on the accuracy of the error rate.
 
“Palmetto’s results did not provide assurance that the FY 2008 DME error rate was accurate. The CERT contractor’s failure to identify 17 errors and its use of limited medical records to infer medical necessity, which was inconsistent with the methodology used by Palmetto and other DME medical review contractors, cast doubt on the accuracy of the FY 2008 DME error rate,” the OIG said.
 
The agency recommended that the CERT contractor develop a corrective action plan to reduce its number of incorrect determinations and perform a complex medical review by obtaining and reviewing all medical records from all relevant providers to support the medical necessity of DME items.
 
CMS concurred with the OIG’s findings and said it had “made significant changes to how it measures the error rate, and, in addition, has clarified its medical review instructions for all contractors.”
 
CMS also said the CERT contractor had already “implemented an internal quality review of DME claims included in the 2009 improper payment report period.” As well, CMS said, the CERT contractor will re-evaluate DME claims for the fiscal year 2009 report.