Medicare Comprehensive Error Rate Testing Improper Payment Data

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The dataset includes detailed information on Medicare fee-for-service (FFS) claims that underwent Comprehensive Error Rate Testing (CERT) medical review for the years 2011 to 2017 report period. These claims were used to calculate the Medicare fee-for-service improper payment rate.

Complexity

The CMS implemented the Comprehensive Error Rate Testing (CERT) program to measure improper payments in the Medicare Fee-for-Service (FFS) program. CERT is designed to comply with the Improper Payments Information Act (IPIA) of 2002, as amended by the Improper Payments Elimination and Recovery Improvement Act (IPERIA) of 2012. The datasets are comprised of information on Medicare fee-for-service (FFS) claims that underwent CERT medical review. These claims were used to calculate the Medicare FFS improper payment rate. A provider can search by Claim Control Number (CCD) and see if their claim was paid or denied.

The objective of the CERT program is to estimate the accuracy of the Medicare FFS program. The CERT process includes 1. Claim Selection 2. Medical Record Requests 3. Review of Claims 4. Assignment of Improper Payment Categories 5. Calculation of the Improper Payment Rate. The CERT Program calculates the paid claims error rate for Medicare claims submitted to Carriers, Durable Medical Equipment Regional Carriers, and Fiscal Intermediaries. The Centers for Medicare and Medicaid Services receives in excess of 2 billion claims per year. CERT randomly selects a statistical sample of these claims for review to determine whether the claims were paid properly. CERT selects a stratified random sample of approximately 40,000 claims submitted to Part A/B Medicare Administrative Contractors (MACs) and Durable Medical Equipment MACs (DMACs) during each reporting period. This sample size allows CMS to calculate a national improper payment rate and contractor- and service-specific improper payment rates. The CERT program ensures a statistically valid random sample; therefore, the improper payment rate calculated from this sample is considered to reflect all claims processed by the Medicare FFS program during the report period. The sample of Medicare FFS claims is reviewed by an independent medical review contractor to determine if they were paid properly under Medicare coverage, coding, and billing rules. If these criteria are not met or the provider fails to submit medical records to support the claim billed, the claim is counted as either a total or partial improper payment and the improper payment may be recouped (for overpayments) or reimbursed (for underpayments). The last step in the process is the calculation of the annual Medicare FFS improper payment rate, which is published in the Health and Human Services (HHS) Agency Financial Report (AFR).

Date Created

2018-03-05

Last Modified

2018-03-05

Version

2018-03-05

Update Frequency

Annual

Temporal Coverage

2011-2017

Spatial Coverage

United States

Source

John Snow Labs => Centers for Medicare and Medicaid Services

Source License URL

John Snow Labs Standard License

Source License Requirements

N/A

Source Citation

N/A

Keywords

Improper Payment of Medicare Insurance, Medicare Fee For Service, CERT Payment, Medicare Claims Processing Manual, Medicare Claim Number, Comprehensive Error Rate Testing (CERT), Medical Billing Errors Statistics, Billing Coding Errors

Other Titles

Improper Payments in Medicare Fee-for-Service (FFS) Program, Annual Medicare FFS Improper Payment Rate, CMS CERT Report on Medical Billing Coding Errors Statistics

Name Description Type Constraints
YearYear of datadate-
Claim_Control_NumberA number assigned by the payer to identify a claim. The number is usually referred to as an Internal Control Number (ICN), Claim Control Number (CCN) or a Document Control Number (DCN)integerlevel : Nominal
Medicare_Plan_PartType of Medicare Fee for Service claimstring-
Diagnosis_Related_GroupThe Diagnosis Related Group code (DRG)integerlevel : Nominal
HCPCS_Procedure_CodeThe Healthcare Common Procedure Coding System codestring-
Provider_TypeType of provider providing the servicestring-
Type_Of_BillType of Bill identifies type of facility, type of care, and sequence of bill in a particular episode of carestring-
Review_DecisionMedical review decision for the claim, either agree or disagreestring-
Error_CodeReason the claim has errorstring-
YearClaim_Control_NumberMedicare_Plan_PartDiagnosis_Related_GroupHCPCS_Procedure_CodeProvider_TypeType_Of_BillReview_DecisionError_Code
20111135600Part B52000UrologyAgree
20111135600Part B81003UrologyAgree
20111134253Part B99254UrologyAgree
20111135614Part B99213UrologyAgree
20111135614Part B81001UrologyAgree
20111134794Part B55700UrologyAgree
20111134794Part B76942UrologyAgree
20111134794Part B76872UrologyAgree
20111134794Part B88305UrologyAgree
20111134794Part BA4550UrologyAgree