CERT Error Focus - Provider Reported Billing Errors
In our continuing effort to increase the awareness of all Medicare providers regarding issues found as a result of CERT reviews, we have been focusing on specific services and provider specialties that contribute to our CERT error rate. In this issue, our focus is on errors related to provider-reported billing errors, and their affect on our CERT error rate.
Analysis of our current CERT error findings (claims submitted 04/01/05-03/31/06) reveals that services reported as billing errors by providers had a greater impact on our error rate than in previous review periods. This was due in part to the relatively high dollar amount of a small number of the claims in this error category. The types of issues involved in these cases were reported as follows:
- The service was performed by another physician
- A clerical error occurred and the service was billed under the wrong patient
- Review of the file shows that the evaluation and management service was billed in error
- The abdominal ultrasound was provided on a different date of service than billed
- Nursing home service was provided on a different date of service than billed
- The patient did not have an EKG on that day
- This service was not performed on the date by this provider
- Secondary [surgery] was not performed. This was billed in error.
It is important that providers use caution when billing services to Medicare Part B. Prior to claims submittal, please ensure the accuracy of the beneficiary and date of service, the performing physician, and the HCPCS code(s). If your office discovers a billing error after a claim has been submitted, please contact WPS Medicare Part B immediately. Minor errors or omissions in filing claims can be corrected by requesting a claim reopening via the appropriate telephone line as indicated below.
Reopenings
All Hours are Local Time
WI 8:00 - 4:00 (877) 674-5354
IL 8:00 - 4:00 (877) 867-3418
MI 8:00 - 4:00 ET (877) 674-5416
MN 8:00 - 4:00 (866) 380-4744
If the claim has processed and it is found that the services billed were not rendered, please submit a refund of the Medicare Part B payment as soon as possible. The check should be made out to "Medicare" and sent to the appropriate address for your state. For more information regarding this process and to obtain a refund form, please visit our website at http://www.wpsmedicare.com/provider/vol_refund_prov_supp.shtml.
Correcting these billing errors in a timely manner can have a positive impact on the CERT error rate. In cases where a claim is corrected or a refund is received prior to inclusion in the CERT transaction file, the CERT contractor will review the latest action on the claim and a CERT error may be avoided.
Proper documentation and accurate billing of services to Medicare Part B is crucial in order to meet CMS' CERT error rate reduction expectations, and WPS continues to identify problem areas contributing most significantly to our jurisdiction's error rate. Continued cooperation from providers is essential in order to reach these goals.
For more information regarding the CERT program and other issues related to CERT review findings, please visit our website at http://www.wpsmedicare.com/provider/cert.shtml. If you have questions related to the CERT process or a specific CERT sampled claim, you may email us at medicareadmin@wpsic.com. Be sure to include "CERT Question" in the subject line. Please also include your full name, telephone number, and Provider Identification Number (if available) in the body of the e-mail. This will assure a prompt and accurate reply to your question.
When e-mailing WPS Medicare, please do not include sensitive information. If your question pertains to a specific claim, include the Internal Control Number, not your patient's Medicare Health Insurance Claim Number.
