CERT Provider Compliance Error Rate
When medical records are requested and reviewed by the CERT Contractor, the review results are tracked and used to produce three types of error rates for all Medicare contractors. These error rates are the Paid Claims Error Rate, Provider Compliance Error Rate, and the No Resolution Rate. In the past, we have stressed the importance of how CERT errors affect the Paid Claims Error Rate. However, another important measurement within the CERT process is the Provider Compliance Error Rate (PCR).
The Provider Compliance Error Rate is based on how the claims looked when they first arrived at the Medicare contractor, before any edits were applied or reviews were conducted. According to CMS, the PCR is a good indicator of how well the contractor is educating the provider community, since it measures how providers prepared claims for submission.
The May 2006 (Mid-Year) CERT report reflected a reduction in our Provider Compliance Error Rate (PCR) from 15.8% in November 2005, to 14.5%. The PCR rate consists of errors associated with denied claims, as well as paid claim errors. Utilizing the May 2006 sample claim dataset (claims submitted 10/01/04-09/30/05) we have begun to look into the effect that denied claims have on our PCR on a state-by-state basis.
The May 2006 dataset shows that claim denials accounted for the largest portion of the PCR, an average of 76.75% across our four state jurisdiction. Further analysis indicates that the following four denial reasons are the most frequent in all states:
- The procedure code submitted is a non-covered Medicare service. (all four states)
- Duplicate charge paid on another claim. (all four states)
- Duplicate charge of another claim now being processed. (all four states)
- Claim must be sent to the Employer Group Health Plan (EGHP) first. (WI/IL/MI)
*In addition to the above 4 reasons, services denied as "This service by a chiropractor is not covered by Medicare" also accounted for a high number of denied claim lines in Wisconsin and Illinois.
Further reductions in our PCR will be dependant upon the cooperation of providers in the proper submission of Medicare claims. To address some of the various issues involved with unnecessary claim submissions and claim denials, our Provider Outreach and Education (POE) staff has developed a seminar entitled "Practical Solutions to your Medicare Claim Denials." These half-day seminars are designed to educate providers on how to avoid claim denials. As part of the session, examples are given of claim submissions which result either in a denial or the need to request an appeal. Please watch for future seminar schedules to be posted on our Website.
