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									     Illinois State Medical Society
                                      (ISMS)
      Wisconsin Physicians Service (WPS)
                                Medicare


Medicare Part B Compliance Issues
               October 2, 2008
               J. David Bozarth, Presenter



       You must dial in to hear the audio portion of
       this Webinar. The dial in number is
       1(800)588-4973 and access code 20039248
       Continuing Medical Education
       (CME)
Faculty Disclosure:
Our planners and faculty have disclosed that they do not
have any relevant financial relationships with any
commercial interests that may have an impact on the
faculty members’ presentations

The Illinois State Medical Society designates this educational
activity for a maximum of 1 AMA PRA Category 1 CreditTM.
Physicians should only claim credit commensurate with the
extent of their participation in the activity.
Learning Objectives:

At the conclusion of this activity, participants will be
  able to:
• Identify current health policy issues that directly
  affect physician practice
• Discuss common challenges to physicians in the
  current healthcare environment and strategies for
  overcoming these challenges
• Explain the significance of ISMS legislative efforts
  and the impact on Illinois physician practices
Illinois State Medical Society (ISMS)
WPS Medicare – October 2, 2008


  Avoiding Claims Rejections / Denials
    “Getting it Right the First Time!”

                  focusing on
Comprehensive Error Rate Testing
            (CERT)

                                         4
Illinois State Medical Society (ISMS)
WPS Medicare – October 2, 2008

            Table of Contents
• Rejections vs. Claims Denials
• Top Reasons All Claims are Rejected
• Comprehensive Error Rate Testing
  (CERT)



                                        5
Illinois State Medical Society (ISMS)
WPS Medicare – October 2, 2008
Rejections vs. Denials
          Unprocessable Rejections
  − Claim is received but does not
    complete processing due to invalid
    or missing information.
  − This rejection is the result of a critical error
  − Look at the claim you submitted and
    determine what was wrong with it. Make
    the correction and re-file it as a new claim.
                                                       6
Illinois State Medical Society (ISMS)
WPS Medicare – October 2, 2008

Rejections vs. Denials (cont’d)
           Unprocessable Rejections
  Examples: Many claims are rejected as
    unprocessable due to simple, but critical
    errors such as:
  − Invalid procedure code/modifier
  − Incorrect provider information
  − Invalid place of service (POS) indicator
                                                7
Illinois State Medical Society (ISMS)
WPS Medicare – October 2, 2008

Top Reasons for
Claims Denials
1. Duplicate claim/service
2. Post-operative care included
3. Bundled service
4. Not payable when performed by this
   specialty
                                        8
Illinois State Medical Society (ISMS)
WPS Medicare – October 2, 2008
Top Reasons for
Claims Denials (cont’d)
5. Medical necessity
6. Missing or invalid attending provider
   number
7. Missing or invalid procedure code
8. Missing or invalid rendering provider
   number
                                           9
Illinois State Medical Society (ISMS)
WPS Medicare – October 2, 2008
        Avoiding Claims Denials
 Periodically reviewing the information on the
   previous slides and putting into action the
  guidance provided will help you avoid claims
              rejections and denials.
 Reducing claims errors is a major goal of WPS,
  and Medicare contractors in general. As such,
    it is very important that we all learn about
     Comprehensive Error Rate Testing
                      (CERT).

                                                   10
What Is CERT?
The Comprehensive Error Rate Testing
  (CERT) program was implemented in
  August 2000 by the Centers for Medicare &
  Medicaid Services (CMS) in order to comply
  with the Government and Results Act of
  1993. Congress mandated that CMS
  determine the accuracy of paid claims by
  Medicare contractors. CMS contracts with
  Program Safeguard Contractors (PSCs) to
  maintain this program.

                                               11
What Is CERT?

These contracted organizations work with
  WPS to produce error rates. CMS then
  publishes the Improper Medicare Fee-For-
  Service (FFS) payments report.
  (Methodologies are available on CMS the
  website.)

  http://www.cms.hhs.gov/CERT/CR/list.asp
  #TopOfPage

                                             12
What Is The Primary Objective?
The primary objective at CMS is to insure that the
  Medicare Fee-for-Service program pays claims
  correctly.

         “Pay it Right the First Time”
In order to meet this goal, Medicare contractors
  must insure that they pay the right amount for
  covered and correctly coded services rendered to
  eligible beneficiaries by legitimate providers.


                                                     13
Overview CERT Process

• Randomly select claim samples submitted in
  calendar year;
• Request medical records from providers who
  submitted claims;




                                               14
Overview CERT Process

Review the claim and medical records to ensure
  claims complied with Medicare coverage, coding,
  and billing rules, developing for additional
  information if needed (Tech Stop); Reviews can
  result in overpayments as well as
  underpayments, and




                                                15
Overview CERT Process

Determine the final results, pass or fail.
  (No Documentation responses are treated
 as errors and overpayment demand letters
 are sent. )




                                             16
Who are the CERT Program Safeguard
         Contractors (PSCs)?




       And what do they do?


                                     17
CERT Documentation Contractor (CDC) vs
CERT Review Contractor (CRC)


The CERT Program calculates the paid claims
  error rate for Medicare claims submitted to
  Carriers, DMERC, and FIs. CMS receives in
  excess of 2 billion claims per year.




                                                18
CERT Documentation Contractor (CDC) vs
CERT Review Contractor (CRC)
 The CERT Program uses two PSC contractors to
 accomplish this work:
 CERT Documentation Contractor (CDC)
     The CERT Documentation Contractor is
     responsible for requesting and receiving the
     medical record documentation from providers.

 CERT Review Contractor (CRC)
     The CRC is responsible for reviewing the selected
     claims and associated medical record
     documentation.

                                                         19
CERT Documentation Contractor
(CDC)

 The CDC is located in Annapolis Junction,
 Maryland and is responsible for the request
 and receipt of medical records for CERT
 sampled claims.
 The CDC will make a telephone contact to the
 provider‟s office in order to obtain a Point of
 Contact (POC) prior to sending the initial
 request for documentation.


                                                   20
CERT Documentation Contractor
(CDC)

 If the contact is successful, the CDC will fax
 (preferred method) or mail the medical record
 request directly to the POC. The contact
 information is retained by the CDC to insure
 that future CERT correspondence is directed to
 the appropriate POC staff and received timely.
 If POC information changes, please send
 notification to the CDC.
      http://www.certprovider.org/default.aspx
    (Monthly CERT newsletters, medical record request example letters,
                     and POC updates are available.)

                                                                         21
Unsuccessful CDC attempts
 The CDC will send up to four requests for
 medical records – this may be in addition to
 placing multiple telephone calls.
 The provider is given a total of 90 days
 to submit the requested documentation. If the
 documentation is not received by this deadline,
 the CDC will notify the Affiliated Contractor
 (AC) via a secure website application.
 The AC is then responsible for issuing a
 demand letter requesting a refund of the
 erroneous Medicare payment for the
 undocumented services.
                                                   22
Provider Contact Schedule
   Day 0: Letter 1
   Day 15: Call 1
   Day 30: Letter 2
   Day 40: Call 2
   Day 50: Letter 3
   Day 60: Call 3
   Day 75: Letter (OIG Referral)
   Day 90: Claim Scored an Error

                                   23
CDC „Second Chance‟
 If a response is received, but elements of the
 documentation is still missing (ex. physician
 orders, lab reports, treatment plan, etc.) the
 CDC will send another letter to the provider
 giving them a “second chance” to send in the
 additional documentation.
 The provider then has 15 days to submit the
 documentation to the CDC or the claim will be
 reviewed based on the original documentation
 and scored as an error.


                                                  24
CDC „Second Chance‟
 If the documentation is not received by this
 deadline, the CDC will again notify the
 Affiliated Contractor via the secure website
 application and the AC will resume with
 collection efforts for the undocumented
 services.




                                                25
26
27
28
29
Where Do I Send Records?
 Requests for medical records may be faxed to
 (240) 568-6222. (Fax is the preferred
 method of delivery.)
 Voluminous pages of medical record
 documentation may be sent via mail to:
    CERT Documentation Office
    9090 Junction Drive, Suite 9
    Annapolis Junction, Maryland 20701


                                                30
CERT Review Contractor (CRC)
 The CERT Review Contractor (CRC) is located in
 Richmond, Virginia and is responsible for review of the
 medical records obtained from the providers. The CRC
 medical review staff consists of nurses, physicians, and
 other qualified healthcare practitioners.
 The medical records are reviewed to verify that
 contractor decisions regarding the claims were accurate
 and based on sound policy, and that the claim was
 submitted properly by the provider.



                                                            31
CERT Review Contractor (CRC)
 If the CRC determines the claim was paid
 incorrectly or is “in error”, they will notify the
 AC bi-monthly via feedback file. If an
 overpayment is found, the AC is required to
 issue a demand letter requesting a refund of
 the erroneous Medicare payment. If an
 underpayment is found, the AC is required to
 process an adjustment for the additional
 Medicare payment.


                                                      32
Sampling of Claims
Randomly select claim samples submitted in
Calendar year;
  The CERT process begins at the Affiliated
  Contractor‟s (AC) processing site where claims
  that have entered the standard claims
  processing system on a given day are extracted
  to create a Claims Universe File.
     This file is transmitted each day to the CMS
     Data Center, where it is routed through a
     random sampling process.

                                                    33
Sampling of Claims
Randomly select claim samples submitted in
calendar year;
  Claims that are selected as part of the sample are
  downloaded to the Sampled Claims Database. This
  database holds all sampled claims from all AC‟s.
     A Claims Transaction File is created from the
     database and this file is transmitted back to the
     AC and matched to the AC's‟ claims history and
     provider files. A Sampled Claims Resolution File,
     a Claims History Replica File, and a Provider
     Address file are created automatically by the AC
     and transmitted to the CMS Data Center.

                                                         34
Reviewing Claims Medical Records

 CRC Reviews the claim and medical records to
 ensure claims complied with Medicare
 coverage, coding, and billing rules, developing
 for additional information if needed (Tech
 Stop); Reviews can result in overpayments as
 well as underpayments,




                                                   35
Reviewing Claims Medical Records

• The information is updated for Affiliated
  Contractor on the secure website application.
  Brief comments are included on information
  missing from medical records.
• AC‟s have the opportunity to contact providers
  to collect the additional information.




                                                   36
Final Results
 CRC determines the outcome of the review and
 assigns applicable errors. Reviews can result in
 overpayments as well as underpayments.
 The information is updated for Affiliated
 Contractor on the secure website application.
 AC‟s initiate the appropriate action for
 overpayments and/or underpayments.



                                                    37
Overpayments vs. Underpayments
 If an error results in an overpayment, AC‟s
 initiate overpayment demand letters.
 If an underpayment decision is made, AC‟s
 initiate a payment for the difference of the
 amount paid on the initial claim and the CRC
 review determination.




                                                38
39
Can I appeal a CERT error?
                Absolutely!
 If CERT changes the payment decision on your
 claim by denying or reducing payment, you are
 entitled to full appeal rights.
 To request an appeal of the CERT
 determination, submit a request with any
 additional documentation to support your case
 to your appropriate AC.


                                                 40
Types of Error Rates Produced
   Paid Claims Error Rate

   Provider Compliance Error Rate

   No Resolution Rate (Formerly, Services
   Processed Error Rate)

 CERT produces claim error rates nationally and for
 various contractor, service, and provider type
 groupings.


                                                      41
Types of Error Rates Produced

 In previous reports CMS produced a „Services
 Processed Error Rate‟ that measured the number of
 services (rather than dollars) improperly processed.
 The Services Processed Error Rate included: claims
 improperly paid, claims improperly denied, and claims
 the contractor could not find. Many found the Services
 Processed Error Rate to be confusing so CMS
 discontinued providing the Services Processed Error
 Rate.



                                                          42
Paid Claims Error Rate

 This rate is based on dollars paid after the
 Medicare contractor made its payment decision
 on the claim.
 The paid claims error rate is the percentage of
 total dollars that all Medicare Fee-for-Service
 (FFS) contractors erroneously paid or denied
 and is a good indicator of how claim errors in
 the Medicare FFS Program influence the trust
 fund.
                                                   43
Paid Claims Error Rate

CMS calculates the gross rate by:
• Dollars overpaid/underpaid / (divided by)
  total dollars paid




                                              44
Provider Compliance Error Rate
 This rate is based on how the claims looked when they
 first arrived at the Carrier/DMERC – before the
 Carrier/DMERC applied any edits or conducted any
 reviews.
 The provider compliance error rate is a good indicator
 of how well the Carrier/DMERC is educating the
 provider community since it measures how well
 providers prepared claims for submission. This error
 rate is quantified in dollars.
 CMS calculates the gross rate by:
  Dollars submitted incorrectly / (divided by) total
     dollars submitted

                                                          45
No Resolution Rate
 This error rate is based on the number of no resolution
 claims the AC has and measures whether the AC was
 able to account for all of its claims included in the
 CERT sample.
 A no resolution claim is one that the CERT program
 sampled on the day the provider submitted the claim
 but was missing from the AC claims processing system
 10-30 days later.
    The provider retracted or canceled the claim
    The AC appropriately/inappropriately
    canceled/coded/deleted the claim

                                                           46
How Will Error Rates be Used?
 CMS will use the error rate findings to
 determine underlying reasons for claim errors
 and to adjust its action plans to improve
 compliance in payment, documentation, and
 provider billing practices.
 The tracking and reporting of error rates helps
 CMS identify emerging trends and implement
 corrective actions designed to accurately
 manage all Medicare FFS contractors‟
 performance.
                                                   47
How Will Error Rates be Used?

• Error rates will provide Medicare FFS
  contractors with the guidance necessary to
  direct claim review activities, provider
  education efforts, and data analysis.
• Carriers/DMERCs/FIs also use the error rate
  findings to adjust their Error Rate Reduction
  Plans.


                                                  48
Error Rate Calculation
 Broken Down
   Nationally
   By Contractor Type (DMERC, Carrier, FI)
   By Contractor
   By Provider Type (hospital, physician, etc.)
   By BETOS code (i.e., consultation, radiology,
   oncology, etc.)



                                                   49
CMS‟ Error Rate Goals
 CMS aims to accomplish three error rate goals
 under the Government Performance and
 Results Act (GPRA).
   Reduce the National Medicare FFS Paid
   Claims Error Rate
   Reduce the Contractor-Specific Paid Claim
   Error Rate
   Decrease the Provider Compliance Error
   Rate
                                                 50
WE STILL HAVE WORK TO DO!




                            51
WPS CERT Goals
 Educate physician and non-physician providers
 about CERT
 Provide education on CERT errors
 Promote Awareness of the Provider
 Compliance Error Rate
 Promote on-going compliance with CERT
 Program requirements
 Provide education of what actions can be taken
 to prevent CERT errors
 Reduce CERT Error Rates
                                                  52
Error Rate Categories
Pass
  No Improper Payment
  (documentation good)
Fail
  No Documentation (No
  Response)
  Insufficient Documentation
  Incorrect Coding
  Medically Unnecessary
  Other


                               53
Documentation Responsibilities

  It is the provider‟s responsibility to
  supply the requested information.
  Providers are responsible for documentation
  regardless of where they are stored or housed.
  If they are not received, an overpayment may
  be initiated.




                                                   54
Documentation Responsibilities


  Failure to respond to CERT requests
  for documentation and submitting
  insufficient documentation to support
  the services billed to Medicare
  continue to have a significant impact
  on our CERT Error Rate as a carrier.




                                          55
Documentation Responsibilities

    Providers can significantly
    impact these error rates by
    sending complete and accurate
    documentation in response to
    CERT requests.




                                    56
Documentation Criteria

     Must be legible
     Should clearly identify patient
     Should include the date of service
     Should identify who performed
     the service
     (provider‟s name and signature)




                                          57
Documentation Criteria (cont’d)

      Must accurately report all pertinent
    facts, findings, and observations
    •Must include appropriate primary
    and subsequent diagnosis for the service
    provided




                                               58
Supportive Documentation

 Documentation must support
 the service billed with:
     Medical Necessity;

     Medicare coverage criteria; and,

     Documentation in the patient‟s record.



                                              59
WPS Top CERT Error Categories

    Incorrect Coding
    Insufficient Documentation
    No Documentation
    Medically Unnecessary Errors
    Other




                                   60
Evaluation & Management Coding

 Evaluation and Management (E&M) services
 are the largest class of Medicare paid services,
 representing more than 40% of the claims
 received.
 The greatest extent of claims paid in
 error is due to E&M codes not justified
 by the documentation submitted. Most
 of these services are over-coded or under-
 coded by physicians. Both overcoding and
 undercoding of E&M services are considered
 errors.

                                                    61
Evaluation & Management Coding

 Inappropriate billing of E&M services (up-
 coding and down-coding) negatively affects
 the Medicare payment error rate and the
 CERT error rate. The reasons are primarily
 related to incomplete, insufficient
 documentation, and incorrect coding. This
 means that there is information missing
 from the medical records and medical
 necessity of services cannot be determined.


                                               62
WPS Top Incorrect E/M Coding Errors

    Services Incorrectly Coded
    Insufficient Documentation
    No Documentation
    Services Billed Were Not Rendered
    No Response Error Assigned After 90
    Days from the Initial Request of Records
    Medically Unnecessary Errors
    Not Covered or Unallowable Service
    Unbundling
    Other

                                               63
Common E&M Documentation Errors
 Key components were not adequately
 documented according to CMS‟ guidelines for
 E/M services to demonstrate that the work of
 the CPT code had been performed (i.e., history,
 examination and medical decision-making
 were not adequately documented to meet the
 level of service billed.)
 Services were rendered by one provider and
 billed by another provider. (i.e., The hospital
 has the records) (Providers are responsible for
 the documentation requested.)
                                                   64
Common E&M Documentation Errors
 The documentation included conflicting
 information, i.e., the diagnosis on the claim was
 not consistent with the diagnosis in the medical
 record; documentation in the history was not
 consistent with the examination; or, the date of
 service on the claim was not the same as the date
 documented in the medical record.
 Emergency room records missing admission
 H&P, notes from rendered physician and/or ER
 nurse documentation with initial hospital care
 record and discharge instructions.
                                                  65
E&M DOCUMENTATION COMPONENTS
 The three key components of an E&M visit:
  − History
  − Examination
  − Medical Decision Making
 Elements Include:
         History
         Examination
         Medical Decision Making
         Counseling
         Coordination of Care
         Nature of Presenting Problem
         Time
                                             66
Documentation of History

The levels of E/M services are based on four
  types of history;
     Problem Focused
     Expanded Problem Focused
     Detailed
     Comprehensive




                                               67
Documentation of History

Each type of history includes some or all of
  the following elements:
    Chief complaint (CC);
    History of present illness (HPI);
    Review of systems (ROS); and
    Past, family and/or social history
    (PFSH)



                                               68
Documentation of Examination
The levels of E/M services are based on four
  types of examination that are defined as
  follows:

    Problem Focused -- a limited
    examination of the affected body area or
    organ system.
    Expanded Problem Focused -- a
    limited examination of the affected body
    area or organ system and other
    symptomatic or related organ system(s).
                                               69
Documentation of Examination
The levels of E/M services are based on four types
  of examination that are defined as follows
  (continued):
  − Detailed -- an extended examination of the
    affected body area(s) and other symptomatic
    or related organ system(s).
  − Comprehensive -- a general multi-system
    examination or complete examination of a
    single organ system.

                                                     70
Documentation
Medical Decision Making
The levels of E/M services recognize
four types of medical decision making;
  Straightforward
  Low Complexity
  Moderate Complexity
  High Complexity




                                         71
Documentation
Medical Decision Making
Medical decision making refers to the complexity of
establishing a diagnosis and/or selecting a
management option as measured by:
   the number of possible diagnoses and/or the
   number of management options that must be
   considered;
   the amount and/or complexity of medical records,
   diagnostic tests, and/or other information that
   must be obtained, reviewed, and analyzed; and
   the risk of significant complications, morbidity,
   and/or mortality, as well as comorbidities
   associated with the patient's presenting
   problem(s), the diagnostic procedure(s), and/or
   the possible management options.
                                                       72
1995 & 1997 E/M Documentation
Guidelines

 Available at:

http://www.wpsmedicare.com/provider/
pdfs/emwkbk.pdf




                                       73
No Documentation Errors
 The provider has failed to submit any type of response
 to the CERT requests for medical records after the 90
 day deadline
 The provider has responded to the request, but has
 submitted something other than medical records. For
 example;
    Provider indicates no such patient exists.
    Provider indicates that no such service was provided
    to the patient.
    Provider indicates they do not have a medical record
    for the date of service in question, but they do have a
    medical record for the same service just a few days
    before or after.
                                                              74
No Documentation Errors
 The provider has responded to the request, but has
 submitted something other than medical records.
 For example;
    Provider indicates that another department within
    the clinic is responsible for fulfilling the
    documentation requests.
    Provider indicates that a third party (ex. hospital
    or nursing home) has the relevant medical record.
    Provider indicates that they have the medical
    record but refuse to provide it without payment for
    copying and mailing services.


                                                          75
Insufficient Documentation Errors
 Provider has submitted records for the initial hospital
 visit, but not the discharge service billed.
 Provider has submitted office visit notes, but there are
 no lab reports to substantiate the blood draw that was
 billed.
 For chiropractic services, the treatment plan was not
 included.
 The medical records are missing the patient name,
 provider signature or date of service.
 The medical records submitted are not legible.
 Provider has submitted office visits notes, but omitted
 the report for the x-ray billed.
                                                            76
Incorrect Coding Errors
 Documentation for consultation supports down code
 from 99253 to 99251. Documentation does not
 substantiate detailed history, detailed exam and
 medical decision making of low complexity.
 Documentation for hospital visit supports down code
 from 99232 to 99231. Documentation does not
 substantiate expanded problem focused history and
 exam, and medical decision making of moderate
 complexity.
 Documentation for emergency room visit supports up
 code from 99281 to 99284 with detailed history,
 detailed exam and medical decision making of
 moderate complexity.


                                                       77
Medically Unnecessary Service Errors
   The required Provider Certification Statement
   (PCS) was not submitted for a scheduled non-
   emergency dialysis ambulance trip
   Plan of treatment, chief complaint, area of
   treatment, and effectiveness of treatment was
   missing from documentation in order to
   support medical necessity of chiropractic
   services.
   Physician order was not submitted to support
   physical therapy services billed

                                               78
Medically Unnecessary Service Errors
  The required physician order and patient symptoms or
  complaints were not submitted to support the sleep
  studies.
  No documentation to substantiate the necessity for the
  office visit billed in conjunction with the blood draw.
  No documentation that the nurse or physician managed
  a condition or illness as required for the E&M code
  billed.
  Advanced Life Support (ALS) ambulance transport is
  not medically necessary per documentation of a
  sprained ankle and patient seeking refill of pain
  medication.

                                                        79
We Recommend
• Keep an E&M guide „handy‟ when coding visits
  and documenting chart notes.
  Providers simulate a review of office records to
  identify CERT vulnerabilities within their
  documentation.




                                                     80
We Recommend
 Keep a copy of the records sent to the CERT
 contractor, (along with confirmation that they
 were sent (i.e., fax confirmation sheets or
 priority tracking numbers).
 Have the records checked before they are sent
 to ensure that all the pertinent records have
 been included.




                                                  81
Reminders
 Respond to Documentation Requests Timely
 Reviews can result in identification of
 overpayments as well as underpayments.
 If CERT changes the payment decision on your
 claim by denying or reducing payment, you can
 still file an appeal with your Medicare
 contractor.



                                                 82
Reminders (cont’d)
 Your support of this process helps protect the
 solvency of the Medicare Program.
 Your cooperation also allows your Medicare
 contractor to provide individualized education
 to you on your specific CERT errors.
 Contact us with any educational requests
 and/or CERT questions.



                                                  83
Error Rate Reduction Plan (ERRP)
 Every November, CMS will post to
 www.cms.hhs.gov/cert, the Medicare Fee-for-
 Service Improper Payments Report that
 includes various types of error rates including
 contractor-specific error rates.
 Within 30 days of CMS‟s posting of the long
 version of the report, all AC‟s and full PSC‟s
 must develop an Error Rate Reduction Plan.
 The ERRP must describe the corrective actions
 they plan to take in order to lower the paid
 claims error rate, claims processing error rate,
 and provider compliance error rate.
                                                    84
ERRP Must Include
   Reasons for error in the contractor‟s
   jurisdiction.
   New adjustments the AC/full PSC has
   made or will make to its MR/LPET
   Strategy.
   New coordination activities under taken
   with other components within AC/full
   PSC (e.g., developing a system to route
   certain provider calls from the provider
   call center to the MR or LPET unit for
   resolution).


                                              85
ERRP Must Include
   New information being communicated to
   providers including the message point and
   the vehicle (e.g. including in post-pay
   denial letters the LCD ID# associated with
   the denial, issuing additional CBRs to every
   provider who bills the three types of service
   with the highest error rate).
   Suggestions on how CMS can help reduce
   the error rate or improve the CERT
   process.



                                                   86
ERRP Plans must Specify

 The AC must work closely with their PSCs.
 The plans must specify both:

   1. Corrective actions they have already
      put in place
   2. Which new corrective actions they
      have planned for the future




                                             87
Who Contributes to ERRP?
        Provider Outreach
        Medical Review
        (Prepay/Postpay)
        Data Analysis
        Customer Service
        Quality Assurance
        Financial
        Claims
        Mailroom

                            88
Why is it important?

   ERRP demonstrates to CMS that we are
   committed to making correct claim
   payments and protecting the Medicare
   Trust Fund.

   ERRP provides an excellent resource tool
   and education for Providers.



                                              89
CMS Comments on ERRP

 CMS routinely calls or comments on new
 items or old items in the ERRP. In some
 cases suggestions and/or corrective actions
 are made to contractors.
 CMS does follow-up from time to time on
 the activities taking place. It is important to
 provide the most up-to-date information
 when commenting in the ERRP.


                                                   90
CERT Tools and Resources
CMS CERT Web page
   www.cms.hhs.gov/cert
   Background
     Reports
     Over-Utilized Codes List
     Copies of CERT Documentation Request
    Letters
     Monthly CERT Newsletters
     CERT Contact Information
     Program Safeguard Information
     Medicare Integrity Program Information
                                              91
92
CERT Tools and Resources

 WPS Medicare CERT Information
 http://www.wpsmedicare.com/provider/
   cert.shtml

 Initial Medlearn Matters article (SE0526)
 for providers to emphasize the importance
 of compliance
  − http://www.cms.hhs.gov/medlearn/ma
    tters/mmarticles/2005/SE0526.pdf

                                             93
CERT Tools and Resources

• Database of searchable
  Medlearn Matters national articles
  http://www.cms.hhs.gov/medlearn/matters/

 CMS Manual instructions issued in Change
 Request 2976 and Change Request 3229:
 http://www.cms.hhs.gov/manuals/pm_trans/
   R67PI.pdf
 http://www.cms.hhs.cov/manuals/pm_trans/
   R77PI.pdf
                                             94
95
CERT Tools and Resources

 Frequently-Asked Questions
 http://www.wpsmedicare.com/provider/cert
   _faq.shtml
 WPS On-line CERT Presentation –
 Computer- Based Training Module
 (CBT)
 – 1 CEU
  http://www.wpsmedicare.com/provider/cert
    _files/frame.html

                                             96
CERT Tools and Resources

 Correct Coding Initiative (CCI)
 Edits
 http://www.cms.hhs.gov/physicians/cciedits

 1995 & 1997
 E/M Documentation Guidelines available
 in the Evaluation and Management guidebook
  http://www.wpsmedicare.com/provider/pdfs
    /emwkbk.pdf


                                              97
WPS Self-Service Contact
Information for Illinois Providers

 http://www.wpsmedicare.com/part_b/selfser
 vice/contact_info.shtml
 Contact Center: (866) 234-7340
 Interactive Voice Response (IVR) Unit:
                  (877) 908-9499
 Medicare Secondary Payer: (866) 345-0275
 Financial Unit: (866) 463-8207

                                             98
WPS Self-Service Contact
Information for Illinois Providers
 http://www.wpsmedicare.com/part_b/selfser
 vice/contact_info.shtml
 Financial Unit: (866) 463-8207
 Electronic Data Interchange (EDI):
                  (877) 567-7261
 Reopenings: (877) 867-3418
 CMS Secure Net Access Portal (C-SNAP):
              (877) 476-8116

                                             99
Provider Address Updates
for Illinois Providers
 Telephone:
 877-908-8476
 The form(s) may also be downloaded from the
 CMS website at
 http://www.cms.hhs.gov/providers/enrollmen
 t/forms/, and mailed to WPS at the appropriate
 address below:
    Wisconsin Physicians Service
    Medicare B Provider Enrollment Unit
    P.O. Box 8248
    Madison, WI 53708-8248
                                                  100
QUESTIONS ?




              101
THANK YOU!




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