News: CMS didn’t use CERT data to identify fraud, OIG says

CDI Strategies - Volume 15, Issue 7

According to an Office of Inspector General (OIG) audit, CMS did not use Comprehensive Error Rate Testing (CERT) data to identify waste or fraud. The audit states that previous OIG reports “recommend using CERT data to identify and focus on providers that were prone to having errors,” and their “objective was to determine whether CMS and its contractors used CERT program data to identify and focus on error-prone providers.”

After reviewing the steps CMS and contractors took to reduce the improper payment rates for 2014 through 2017 including analyzing CERT program data to identify error-prone providers, the OIG found that CMS did not use CERT data. Using CERT data in the audit, the OIG identified 100 error-prone providers from 2014 through 2017. According to the audit, of the $5.8 million reviewed by CERT, $3.5 million was incorrect. This accounts for an improper payment rate of 60.7%, and the OIG determined that during the same time period Medicare made $19.1 billion fee-for service-payments to the found 100 error-prone providers.

The OIG recommends that CMS review the list of the 100 error-prone providers and take specific appropriate action, such as prior authorization, prepayment reviews, and postpayment reviews. The OIG also recommends that CMS use annual CERT data “to identify individual providers that have an increased risk of receiving improper payments and apply additional program integrity tools to these providers.”

CMS has disagreed with the OIG methodology for identifying error-prone providers, and also noted that it has “previously attempted to use CERT data to identify error-prone providers and suppliers but found that CERT data was ineffective for this purpose and discontinued the practice.”

Editor’s note: The OIG audit can be found here. ACDIS coverage of other CERT related improper payments can be found here.

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Denials & Appeals, News

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