Improper Medicare Fee-For-Service Payments Report - November 2007  A Report

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TABLE OF CONTENTS


  List of Acronyms
  Appendix B: Projected Improper Payments by Cluster
  Appendix C: Error Rates by Cluster and Provider Type
    Appendix C: Part B Contractors
    Appendix C: DME Contractors
    Appendix C: Part A Contractors
  Appendix D: No Documentation Information
    Appendix D: Reasons for No Documentation Errors
  Appendix E: Coding Information
  Appendix F: Overpayments
  Appendix G: Underpayments
  Appendix H: Statistics and Other Information for the CERT Sample

Index of Key Items (Tables and Charts)

Appendix B: Projected Improper Payments by Cluster
   Table : Actual and Projected Improper Payments: Part B Contractors
   Table : Actual and Projected Improper Payments: DME Contractors
   Table : Actual and Improper Payments: Part A Contractors
   Table : Improper Payments: QIOs
Appendix C: Part B Contractors
   Table : AdminaStar IN/KY 00630/00660
   Table : BCBS AR AR/NM/OK/MO/LA 00520/00521/00522/00523/00528
   Table : CIGNA ID 05130
   Table : CIGNA NC 05535
   Table : CIGNA TN 05440
   Table : Cahaba AL/GA/MS 00510/00511/00512
   Table : First Coast Service Options FL 00590
   Table : First Coast Service Options CT 00591
   Table : BCBS KS/NE/W MO 00650/00655/00651
   Table : BCBS MT 00751
   Table : HealthNow NY 00801
   Table : Empire NY 00803
   Table : Empire NJ 00805
   Table : Nordian ND/CO/WY/IA/SD 00820/00824/00825/00826/00889
   Table : Nordian AK/AZ/HI/NV/OR/WA 00831/00832/00833/00834/00835/00836
   Table : HGSA PA 00865
   Table : BCBS AR RI 00524
   Table : Palmetto SC 00880
   Table : Palmetto OH/WV 00883/00884
   Table : Trailblazer TX 00900
   Table : Trailblazer MD/DE/DC/VA 00901/00902/00903/00904
   Table : Noridian UT 00823
   Table : Triple S, INC. PR/VI 00973/00974
   Table : GHI NY 14330
   Table : NHIC CA 31140/31146
   Table : NHIC ME/MA/NH/VT 31142/31143/31144/31145
   Table : WPS WI/IL/MI/MN 00951/00952/00953/00954
   Table : Noridian AZ/MT/ND/SD/UT/WY Part B MAC Region 3 03102/03202/03302/03502
Appendix C: DME Contractors
   Table : AdminaStar Region B 00635
   Table : TriCenturion Region A 77011
   Table : Palmetto Region C 00885
   Table : CIGNA Region D 05655
   Table : NHIC DME MAC Region A 16003
   Table : National Government Services MAC DME Region B 17003
   Table : Noridian Administrative Services DME MAC Region D 19003
Appendix C: Part A Contractors
   Table : AdminaStar IN/IL/KY/OH 00130/00131/00160/00332
   Table : Anthem ME/MA 00180/00181
   Table : Anthem NH/VT 00270
   Table : Cahaba AL 00010
   Table : BCBS AR AR 00020
   Table : BCBS AZ AZ 00030
   Table : First Coast Service Options FL 00090
   Table : BCBS GA GA 00101
   Table : Cahaba IA/SD 00011
   Table : BCBS KS KS 00150
   Table : TriSpan LA/MO/MS 00230
   Table : BCBS MT MT 00250
   Table : Palmetto NC 00382
   Table : BCBS NE NE 00260
   Table : BCBS AR RI 00021
   Table : Palmetto SC 00380
   Table : BCBS WY WY 00460
   Table : Highmark Medicare Services DC/MD 00366
   Table : COSVI PR/VI 57400
   Table : Empire CT/DE/NY 00308
   Table : Chisholm OK 00340
   Table : Veritus PA 00363
   Table : Mutual of Omaha (all states) 52280
   Table : Noridian MN/ND 00320/00321
   Table : Noridian AK/WA 00322
   Table : Noridian ID/OR/UT 00323/00325
   Table : Riverbend NJ/TN 00390
   Table : Trailblazer CO/NM/TX 00400
   Table : UGS AS/CA/GU/HI/NV/NMI 00454
   Table : UGS WI/MI 00450/00452
   Table : UGS VA/WV 00453
   Table : Noridian Part A MAC Region 3 03001
Appendix D: No Documentation Information
   Table : Overall Rates for No Documentation
   Table : Part B Contractor Rates for No Documentation
   Table : DME Contractor Rates for No Documentation
   Table : Part A Rates for No Documentation
Appendix D: Reasons for No Documentation Errors
   Table : Type of No Documentation Errors for Part B Contractor
   Table : Type of No Documentaiton Errors for DME Contractors
   Table : Type of No Documentaiton Errors for Part A
Appendix E: Coding Information
   Table : Problem Code: CPT Code 99233
   Table : Problem Code: CPT Code 99214
   Table : Problem Code: CPT Code 99232
   Table : E&M Codes with more than 2,000 claims reviewed
   Table : Services with Overcoding Errors: Part B
   Table : Services with Overcoding Errors: DME
   Table : Services with Overcoding Errors: Part A
Appendix F: Overpayments
   Table : Service Specific Overpayment Rates: Part B
   Table : Service Specific Overpayment Rates: DME
   Table : Service Specific Overpayment Rates: Part A
   Table : Service Specific Overpayment Rates: Carrier/DMERC/FI/MAC
Appendix G: Underpayments
   Table : Service Specific Underpayment Rates: Part B
   Table : Service Specific Underpayment Rates: DMERCs/DME MACs
   Table : Service Specific Underpayment Rates: Part A
   Table : Service Specific Underpayment Rates: Carrier/DMERC/FI/MAC
Appendix H: Statistics and Other Information for the CERT Sample
   Table : Carrier Size of Universe and Size of Review Sample
   Table : DMERC Size of Universe and Size of Review Sample
   Table : FI Size of Universe and Size of Review Sample
   Table : Claims in Error: Part B
   Table : Claims in Error: DME
   Table : Claims in Error: Part A
   Table : Table H3: Included and Excluded in the Sample
   Table : Frequency of Claims that are Included and Excluded From Each Error Rate: Part B
   Table : Frequency of Claims that are Included and Excluded from Each Error Rate: DME
   Table : Frequency of Claims that are Included and Excluded From Each Error Rate: Part A

LIST OF ACRONYMS

AC Affiliated Contractor

AMA American Medical Association

BBA Balanced Budget Act of 1997

BETOS Berenson-Eggers Type of Service

CAFM Contractor Administrative-Budget and Financial Management System

CDAC Clinical Data Abstraction Center

CERT Comprehensive Error Rate Testing

CMN Certificate of Medical Necessity

CMS Centers for Medicare & Medicaid Services

CPT Current Procedural Terminology

CTRDS CERT Tracking and Reporting Database and System

CY Calendar Year

DARN Dollars at Risk of No Documentation

DHHS Department of Health and Human Services

DRG Diagnosis Related Group

DME Durable Medical Equipment

DMERC Durable Medical Equipment Regional Carrier

E&M Evaluation and Management

EMR Electronic Medial Records

ESRD End Stage Renal Disease

FFS Fee-for-Service

FI Fiscal Intermediary

FY Fiscal Year

GPRA Government Performance & Results Act of 1993

HCPCS Healthcare Common Procedure Coding System

HHA Home Health Agency

HICN Health Insurance Claim Number

HIPAA Health Insurance Portability and Accountability Act of 1996

HI Hospital Insurance

HPMP Hospital Payment Monitoring Program

ICD-9-CM International Classification of Diseases (10th Revision) Clinical Modification

IPIA Improper Payment Information Act

LCD Local Coverage Determination

LI Line Item

MAC Medicare Administrative Contractor

MMA Medicare Modernization Act

MFS Medicare Fee Schedule

MIP Medicare Integrity Program

MSP Medicare Secondary Payer

NCH National Claims History

OIG Office of the Inspector General

OPPS Outpatient Prospective Payment System

POE Provider Outreach and Education

PPS Prospective Payment System

PSC Program Safeguard Contractor

QIO Quality Improvement Organization

RAC Recovery Audit Contractors

RAP Request for Anticipated Payment

RHC Rural Health Clinic

RHHI Regional Home Health Intermediary

RTP Return to Provider

SNF Skilled Nursing Facility


APPENDIX B: PROJECTED IMPROPER PAYMENTS BY CLUSTER

Tables in this section of the appendix contain improper payment amounts for clusters. In the 2003 and 2004 reports, the CERT program provided error rates and improper payment amounts for each cluster. The MMA included a provision and additional funding to allow CMS to temporarily produce error rates at the individual contractor level, in addition to the cluster level rates, for the 2005 and 2006 reports. Beginning with the May 2007 Report, CERT reverts to reporting only cluster level error rates. Beginning with the November 2007 Report, clusters are listed for each contractor that adjudicated claims during the sampling period. There may be some contractors listed that no longer process claims for Medicare FFS. In addition, MACs which began their contracts during the sampling period are listed, but may have less than a full year of data.

Table B1a contains improper payment amounts for Carrier clusters. The table is sorted in descending order by projected improper payment amounts for Carrier cluster values.


B1a: Actual and Projected Improper Payments: Part B Contractors

Sort This Table
Carrier Cluster Actual Overpymt Actual Underpymt Actual Improper Payment Projected Overpymt Projected Underpymt Projected Improper Payment
First Coast Service Options FL 00590 $37,380 $387 $37,767 $775,436,055 $8,028,911 $783,464,966
NHIC CA 31140/31146 $10,500 $328 $10,828 $292,909,393 $9,211,641 $302,121,034
WPS WI/IL/MI/MN 00951/00952/00953/00954 $6,998 $444 $7,442 $276,953,075 $17,222,583 $294,175,659
Empire NY 00803 $17,115 $377 $17,491 $249,748,140 $5,495,327 $255,243,467
Empire NJ 00805 $15,336 $458 $15,793 $227,749,786 $6,796,180 $234,545,967
Trailblazer TX 00900 $8,233 $257 $8,490 $189,897,448 $5,930,107 $195,827,556
Cahaba AL/GA/MS 00510/00511/00512 $8,117 $521 $8,637 $168,815,964 $11,272,514 $180,088,478
BCBS AR AR/NM/OK/MO/LA 00520/00521/00522/00523/00528 $8,285 $498 $8,783 $158,145,724 $9,284,481 $167,430,205
Noridian AK/AZ/HI/NV/OR/WA 00831/00832/00833/00834/00835/00836 $8,037 $211 $8,248 $136,681,522 $3,444,595 $140,126,116
Trailblazer MD/DE/DC/VA 00901/00902/00903/00904 $9,244 $309 $9,553 $129,958,106 $4,299,658 $134,257,765
Palmetto OH/WV 00883/00884 $7,495 $161 $7,655 $123,624,416 $2,648,868 $126,273,284
CIGNA NC 05535 $7,596 $1,311 $8,907 $91,809,062 $15,850,130 $107,659,193
HGSA PA 00865 $6,150 $247 $6,397 $90,038,025 $3,609,450 $93,647,474
AdminaStar IN/KY 00630/00660 $4,884 $1,192 $6,076 $69,344,358 $15,646,140 $84,990,497
NHIC ME/MA/NH/VT 31142/31143/31144/31145 $6,275 $481 $6,755 $69,168,943 $5,298,564 $74,467,507
Noridian ND/CO/WY/IA/SD 00820/00824/00825/00826/00889 $6,216 $664 $6,881 $56,217,240 $5,910,433 $62,127,673
CIGNA TN 05440 $5,913 $478 $6,391 $49,906,883 $4,033,625 $53,940,509
BCBS KS/NE/W MO 00650/00655/00651 $5,800 $928 $6,728 $42,237,800 $6,723,886 $48,961,686
Palmetto SC 00880 $8,750 $510 $9,260 $41,094,055 $2,395,826 $43,489,882
HealthNow NY 00801 $5,834 $284 $6,118 $41,433,801 $2,013,945 $43,447,746
Triple S, Inc. PR/VI 00973/00974 $19,365 $629 $19,995 $38,731,752 $1,257,116 $39,988,868
First Coast Service Options CT 00591 $6,685 $434 $7,119 $35,203,199 $2,282,944 $37,486,143
GHI NY 14330 $7,942 $1,082 $9,025 $15,316,445 $2,087,275 $17,403,719
Noridian MAC Region 3 03002 $6,808 $642 $7,450 $10,127,123 $404,190 $10,531,313
Noridian UT 00823 $4,664 $295 $4,959 $9,661,709 $611,612 $10,273,321
BCBS AR RI 00524 $7,938 $276 $8,215 $8,295,618 $288,895 $8,584,513
CIGNA ID 05130 $3,642 $439 $4,080 $4,009,852 $483,073 $4,492,925
BCBS MT 00751 $2,499 $220 $2,719 $3,037,173 $267,420 $3,304,593
Combined $253,701 $14,062 $267,762 $3,405,552,666 $152,799,391 $3,558,352,057

Table B2a contains actual and projected improper payment amounts for DMERC clusters. The table is sorted in descending order by projected improper payments.

B2a: Actual and Projected Improper Payments: DME Contractors

Sort This Table
DMERC Cluster Actual Overpymt Actual Underpymt Actual Improper Payment Projected Overpymt Projected Underpymt Projected Improper Payment
Palmetto Region C 00885 $91,660 $80 $91,739 $769,359,033 $667,714 $770,026,748
Noridian Administrative Services MAC Region D 19003 $17,493 $942 $18,435 $56,794,871 $3,058,960 $59,853,831
National Government Services MAC Region B 17003 $14,896 $31 $14,927 $46,447,189 $96,601 $46,543,790
CIGNA Region D 05655 $5,510 $0 $5,510 $40,436,437 $0 $40,436,437
AdminaStar Region B 00635 $4,837 $0 $4,837 $38,978,608 $0 $38,978,608
NHIC MAC Region A 16003 $7,869 $0 $7,869 $32,691,723 $0 $32,691,723
Tricenturion Region A 77011 $2,734 $0 $2,734 $27,101,350 $0 $27,101,350
Combined $144,998 $1,053 $146,050 $1,011,809,210 $3,823,276 $1,015,632,486

Table B3a contains FI-specific improper payment amounts for FI clusters. The table is sorted in descending order by projected improper payment amounts.

B3a: Actual and Improper Payments: Part A Contractors

Sort This Table
FI Cluster Actual Overpymt Actual Underpymt Actual Improper Payment Projected Overpymt Projected Underpymt Projected Improper Payment
UGS AS/CA/GU/HI/NV/NMI 00454 $54,384 $2,047 $56,431 $214,098,180 $8,058,128 $222,156,308
Palmetto SC 00380 $44,489 $9,861 $54,351 $154,289,132 $34,199,396 $188,488,528
Mutual of Omaha (all states) 52280 $20,673 $768 $21,441 $127,407,089 $4,732,248 $132,139,337
Highmark Medicare Services DC/MD 00366 $32,502 $4,559 $37,061 $86,844,847 $12,180,264 $99,025,111
UGS WI/MI 00450/00452 $10,692 $289 $10,982 $87,067,739 $2,118,434 $89,186,173
AdminaStar IN/IL/KY/OH 00130/00131/00160/00332 $10,297 $834 $11,131 $78,915,650 $6,624,232 $85,539,881
Trailblazer CO/NM/TX 00400 $15,748 $2,674 $18,422 $60,872,834 $10,336,453 $71,209,287
Riverbend NJ/TN 00390 $10,112 $2,882 $12,994 $41,521,438 $11,835,299 $53,356,738
Anthem ME/MA 00180/00181 $16,035 $6,138 $22,173 $36,511,502 $14,126,835 $50,638,337
Trispan LA/MO/MS 00230 $21,416 $15,097 $36,513 $28,859,374 $20,344,516 $49,203,890
First Coast Service Options FL 00090 $13,805 $1,761 $15,566 $36,393,836 $4,643,135 $41,036,972
Empire CT/DE/NY 00308 $9,673 $341 $10,013 $38,395,723 $1,351,848 $39,747,571
Palmetto NC 00382 $23,476 $339 $23,815 $31,655,821 $457,452 $32,113,273
Anthem NH/VT 00270 $43,509 $1,092 $44,601 $26,957,514 $676,345 $27,633,859
Noridian ID/OR/UT 00323/00325 $13,804 $579 $14,383 $19,732,921 $554,951 $20,287,872
UGS VA/WV 00453 $7,886 $408 $8,294 $16,117,942 $833,789 $16,951,731
Veritus PA 00363 $4,932 $192 $5,124 $14,273,012 $555,211 $14,828,224
BCBS GA GA 00101 $7,817 $1,307 $9,124 $12,473,202 $2,085,266 $14,558,467
Cahaba IA/SD 00011 $3,982 $1,450 $5,432 $9,296,636 $3,386,545 $12,683,181
Noridian MN/ND 00320/00321 $7,943 $114 $8,056 $12,207,941 $174,770 $12,382,711
Noridian AK/WA 00322 $8,284 $2,422 $10,707 $5,454,614 $1,594,908 $7,049,521
BCBS AR AR 00020 $8,498 $4,670 $13,167 $3,260,135 $1,791,500 $5,051,634
Cahaba AL 00010 $2,877 $2,793 $5,670 $2,433,686 $2,362,013 $4,795,699
Noridian MAC Region 3 03001 $33,711 $4,229 $37,940 $4,185,859 $364,320 $4,550,179
BCBS KS KS 00150 $8,955 $90 $9,045 $4,429,920 $44,344 $4,474,264
BCBS NE NE 00260 $5,005 $3,979 $8,984 $1,271,700 $1,011,011 $2,282,710
BCBS AZ AZ 00030 $4,785 $210 $4,994 $2,158,135 $94,640 $2,252,775
BCBS AR RI 00021 $11,155 $854 $12,009 $1,832,171 $140,293 $1,972,464
COSVI PR/VI 57400 $14,105 $548 $14,653 $1,514,190 $58,807 $1,572,998
Chisholm OK 00340 $3,241 $574 $3,815 $1,098,512 $194,452 $1,292,964
BCBS MT MT 00250 $1,949 $37 $1,985 $843,284 $15,881 $859,165
BCBS WY WY 00460 $8,854 $382 $9,236 $518,901 $22,399 $541,300
Combined $484,593 $73,518 $558,112 $1,162,893,439 $146,969,684 $1,309,863,123

 

B4a: Improper Payments: QIOs

Sort This Table
QIO Cluster Actual Overpymt Actual Underpymt Actual Improper Payment Projected Overpymt Projected Underpymt Projected Improper Payment
Short-term Acute Paid Claims N/A N/A N/A $4,093,544,211 $642,562,928 $4,736,107,139
Long-term Acute Paid Claims N/A N/A N/A $172,729,661 $29,777,173 $202,506,834
Denied Claims N/A N/A N/A $0 $9,241,619 $9,241,619
Total N/A N/A N/A $4,266,273,872 $681,581,720 $4,947,855,592


APPENDIX C: ERROR RATES BY CLUSTER AND PROVIDER TYPE

Tables in this section of the appendix provide data by cluster. Each table in the appendix includes three error rates for each provider type that billed contractors in the cluster. The three error rates are:

  • Paid/Allowed Claims Error Rate,
  • Provider Compliance Error Rate (except FIs), and
  • No Resolution Rate.

Information on dollars in error is also included in the tables. The table sort defaults to descending order by projected improper payments.


Appendix C: Part B Contractors

C1a: AdminaStar IN/KY 00630/00660

Sort This Table
Carrier Provider Type Paid Claims Error Rate Provider Compliance Error Rate No Resolution Rate
Paid Error Rate Projected Improper Payments Standard Error 95% Confidence Interval
All Provider Types With Less Than 30 Claims 2.2% $19,914,920 0.7% 0.9% - 3.4% 10.6% 0.0%
Family Practice 7.5% $15,890,248 1.3% 4.9% - 10.1% 15.9% 0.0%
Hematology/Oncology 10.1% $12,444,150 8.9% ( 7.3%) - 27.4% 30.4% 0.0%
Cardiology 3.3% $10,171,991 1.2% 1.0% - 5.5% 4.4% 0.0%
Internal Medicine 3.7% $9,985,281 0.9% 2.0% - 5.4% 13.6% 0.0%
Podiatry 10.9% $4,628,497 4.3% 2.5% - 19.4% 23.6% 0.0%
Orthopedic Surgery 3.1% $3,668,009 1.6% ( 0.1%) - 6.3% 11.3% 0.0%
Dermatology 5.6% $2,435,971 3.4% ( 1.1%) - 12.3% 6.3% 0.0%
Chiropractic 7.8% $1,955,753 4.4% ( 0.9%) - 16.5% 24.0% 0.0%
Diagnostic Radiology 1.0% $1,202,799 1.0% ( 1.0%) - 3.0% 8.8% 0.0%
Ophthalmology 1.0% $1,006,537 0.8% ( 0.5%) - 2.5% 7.6% 0.0%
Psychiatry 3.5% $628,240 3.3% ( 2.9%) - 10.0% 13.9% 0.0%
Optometry 1.1% $459,123 1.1% ( 1.0%) - 3.3% 12.8% 0.0%
Nurse Practitioner 1.7% $307,245 1.7% ( 1.6%) - 4.9% 11.4% 0.0%
Emergency Medicine 0.5% $291,734 0.5% ( 0.5%) - 1.4% 12.6% 0.0%
Ambulance Service Supplier (e.g., private ambulance companies, funeral homes) 0.0% $0 0.0% 0.0% - 0.0% 5.7% 0.0%
Clinical Laboratory (Billing Independently) 0.0% $0 0.0% 0.0% - 0.0% 2.5% 0.0%
Pulmonary Disease 0.0% $0 0.0% 0.0% - 0.0% 1.4% 0.0%
All Provider Types 3.1% $84,990,497 0.5% 2.1% - 4.1% 11.1% 0.0%

C1b: BCBS AR AR/NM/OK/MO/LA 00520/00521/00522/00523/00528

Sort This Table
Carrier Provider Type Paid Claims Error Rate Provider Compliance Error Rate No Resolution Rate
Paid Error Rate Projected Improper Payments Standard Error 95% Confidence Interval
All Provider Types With Less Than 30 Claims 3.4% $45,120,838 0.7% 2.0% - 4.7% 11.5% 0.0%
Family Practice 8.7% $28,907,341 3.7% 1.5% - 15.9% 15.5% 0.0%
Internal Medicine 7.8% $28,758,999 2.3% 3.3% - 12.3% 18.7% 0.0%
Cardiology 5.1% $16,320,153 1.6% 2.0% - 8.3% 15.4% 0.0%
Psychiatry 17.0% $8,554,347 8.2% 0.9% - 33.1% 26.6% 0.0%
Diagnostic Radiology 2.9% $7,108,187 1.8% ( 0.7%) - 6.5% 10.5% 0.0%
General Surgery 5.1% $5,243,686 2.5% 0.2% - 10.1% 11.5% 0.0%
General Practice 8.2% $4,479,755 3.9% 0.5% - 15.9% 13.1% 0.0%
Hematology/Oncology 1.6% $4,368,086 1.1% ( 0.6%) - 3.9% 3.6% 0.0%
Emergency Medicine 4.8% $3,620,220 2.7% ( 0.6%) - 10.1% 9.0% 0.0%
Chiropractic 8.3% $3,490,375 4.3% ( 0.1%) - 16.8% 23.3% 0.0%
Urology 1.6% $3,043,719 1.1% ( 0.5%) - 3.6% 3.6% 0.0%
Pulmonary Disease 4.6% $2,987,288 2.4% ( 0.0%) - 9.3% 10.7% 0.0%
Orthopedic Surgery 1.1% $2,904,810 0.6% ( 0.1%) - 2.4% 6.8% 0.0%
Ambulance Service Supplier (e.g., private ambulance companies, funeral homes) 0.5% $1,047,127 0.4% ( 0.2%) - 1.1% 24.0% 0.0%
Clinical Laboratory (Billing Independently) 0.8% $854,237 0.8% ( 0.8%) - 2.3% 5.9% 0.0%
Podiatry 0.8% $421,094 0.7% ( 0.6%) - 2.2% 22.3% 0.0%
Nurse Practitioner 0.7% $199,944 0.7% ( 0.7%) - 2.1% 21.4% 0.0%
Ophthalmology 0.0% $0 0.0% 0.0% - 0.0% 10.8% 0.0%
All Provider Types 3.9% $167,430,205 0.5% 2.9% - 4.8% 12.6% 0.0%

C1c: CIGNA ID 05130

Sort This Table
Carrier Provider Type Paid Claims Error Rate Provider Compliance Error Rate No Resolution Rate
Paid Error Rate Projected Improper Payments Standard Error 95% Confidence Interval
All Provider Types With Less Than 30 Claims 1.2% $970,528 0.4% 0.5% - 1.9% 14.5% 0.0%
Family Practice 4.5% $945,919 1.5% 1.5% - 7.4% 12.1% 0.0%
Cardiology 4.4% $650,010 1.5% 1.5% - 7.3% 14.1% 0.0%
Internal Medicine 3.5% $427,556 1.2% 1.1% - 5.9% 14.7% 0.0%
Physician Assistant 5.4% $278,754 2.5% 0.5% - 10.3% 18.4% 0.0%
Chiropractic 9.4% $273,611 4.9% ( 0.3%) - 19.1% 30.8% 0.0%
Orthopedic Surgery 2.7% $158,305 1.6% ( 0.4%) - 5.7% 32.1% 0.0%
Dermatology 2.9% $145,180 1.7% ( 0.3%) - 6.2% 4.0% 0.0%
Emergency Medicine 3.0% $119,216 1.9% ( 0.6%) - 6.7% 8.1% 0.0%
Diagnostic Radiology 1.0% $115,582 1.0% ( 0.9%) - 2.9% 4.0% 0.0%
Physical Therapist in Private Practice 1.2% $105,815 0.9% ( 0.6%) - 3.0% 8.1% 0.0%
Nurse Practitioner 7.6% $96,863 4.2% ( 0.6%) - 15.8% 26.0% 0.0%
Ophthalmology 0.4% $62,608 0.3% ( 0.2%) - 0.9% 5.7% 0.0%
General Surgery 0.6% $56,773 0.5% ( 0.3%) - 1.6% 24.9% 0.0%
Urology 1.3% $53,932 0.9% ( 0.5%) - 3.1% 6.9% 0.0%
Podiatry 1.2% $32,273 1.2% ( 1.2%) - 3.6% 13.3% 0.0%
Clinical Laboratory (Billing Independently) 0.0% $0 0.0% 0.0% - 0.0% 11.3% 0.0%
Optometry 0.0% $0 0.0% 0.0% - 0.0% 27.8% 0.0%
Pathology 0.0% $0 0.0% 0.0% - 0.0% 23.1% 0.0%
All Provider Types 2.1% $4,492,925 0.3% 1.6% - 2.6% 14.2% 0.0%

C1d: CIGNA NC 05535

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Carrier Provider Type Paid Claims Error Rate Provider Compliance Error Rate No Resolution Rate
Paid Error Rate Projected Improper Payments Standard Error 95% Confidence Interval
All Provider Types With Less Than 30 Claims 7.2% $53,298,241 2.2% 2.9% - 11.5% 15.8% 0.0%
Internal Medicine 6.1% $20,117,775 1.7% 2.8% - 9.4% 12.0% 0.0%
Family Practice 7.2% $8,536,982 2.1% 3.2% - 11.3% 18.7% 0.0%
Orthopedic Surgery 5.6% $5,823,757 2.5% 0.6% - 10.5% 21.0% 0.0%
Cardiology 3.0% $5,081,963 1.5% 0.1% - 5.9% 6.5% 0.0%
Emergency Medicine 5.3% $2,739,333 2.2% 1.0% - 9.6% 15.5% 0.0%
Chiropractic 12.4% $2,111,280 5.0% 2.5% - 22.2% 31.0% 0.0%
Optometry 4.9% $1,740,080 2.7% ( 0.3%) - 10.1% 22.3% 0.0%
Urology 3.1% $1,685,929 1.5% 0.1% - 6.1% 2.6% 0.0%
Gastroenterology 2.4% $1,629,119 1.6% ( 0.7%) - 5.6% 11.1% 0.0%
Hematology/Oncology 2.0% $1,610,505 1.1% ( 0.2%) - 4.2% 6.0% 0.0%
Diagnostic Radiology 0.7% $1,415,900 0.7% ( 0.7%) - 2.1% 4.2% 0.0%
Ophthalmology 0.6% $941,476 0.6% ( 0.6%) - 1.7% 2.3% 0.0%
Ambulance Service Supplier (e.g., private ambulance companies, funeral homes) 0.4% $535,707 0.4% ( 0.4%) - 1.1% 9.7% 0.0%
Clinical Laboratory (Billing Independently) 0.3% $391,143 0.2% ( 0.0%) - 0.7% 3.2% 0.0%
All Provider Types 4.5% $107,659,193 0.8% 3.0% - 6.0% 11.8% 0.0%

C1e: CIGNA TN 05440

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Carrier Provider Type Paid Claims Error Rate Provider Compliance Error Rate No Resolution Rate
Paid Error Rate Projected Improper Payments Standard Error 95% Confidence Interval
All Provider Types With Less Than 30 Claims 3.0% $15,549,203 0.8% 1.4% - 4.5% 14.2% 0.0%
Internal Medicine 5.4% $9,312,878 1.4% 2.8% - 8.1% 12.5% 0.0%
Cardiology 3.2% $5,654,655 1.1% 1.0% - 5.4% 10.3% 0.0%
Family Practice 4.6% $5,403,233 1.2% 2.2% - 6.9% 18.3% 0.0%
Ambulance Service Supplier (e.g., private ambulance companies, funeral homes) 5.4% $4,915,836 3.4% ( 1.3%) - 12.0% 12.5% 0.0%
Clinical Laboratory (Billing Independently) 4.1% $2,623,169 3.0% ( 1.7%) - 10.0% 11.5% 0.0%
Pulmonary Disease 7.4% $2,397,405 3.8% ( 0.1%) - 14.9% 10.8% 0.0%
Nurse Practitioner 3.4% $1,511,396 1.3% 0.9% - 5.9% 6.7% 0.0%
General Surgery 2.1% $1,441,262 1.4% ( 0.6%) - 4.8% 8.8% 0.0%
Hematology/Oncology 0.6% $1,094,977 0.3% ( 0.1%) - 1.2% 3.8% 0.0%
Emergency Medicine 2.2% $1,052,694 1.2% ( 0.1%) - 4.6% 10.1% 0.0%
Orthopedic Surgery 1.4% $864,656 0.8% ( 0.2%) - 3.1% 28.5% 0.0%
Chiropractic 9.8% $788,613 5.1% ( 0.3%) - 19.8% 50.8% 0.0%
Ophthalmology 1.2% $718,057 0.9% ( 0.6%) - 2.9% 5.3% 0.0%
Diagnostic Radiology 0.3% $330,249 0.2% ( 0.1%) - 0.8% 5.8% 0.0%
Dermatology 0.9% $282,226 0.6% ( 0.2%) - 2.1% 16.4% 0.0%
Optometry 0.0% $0 0.0% 0.0% - 0.0% 18.1% 0.0%
All Provider Types 3.0% $53,940,509 0.4% 2.2% - 3.8% 12.6% 0.0%

C1f: Cahaba AL/GA/MS 00510/00511/00512

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Carrier Provider Type Paid Claims Error Rate Provider Compliance Error Rate No Resolution Rate
Paid Error Rate Projected Improper Payments Standard Error 95% Confidence Interval
All Provider Types With Less Than 30 Claims 3.6% $44,126,010 1.1% 1.4% - 5.7% 17.7% 0.0%
Internal Medicine 8.4% $37,886,986 1.5% 5.5% - 11.3% 18.7% 0.0%
Family Practice 7.1% $18,928,722 1.8% 3.7% - 10.5% 21.8% 0.0%
Cardiology 3.1% $14,418,577 1.3% 0.5% - 5.7% 12.1% 0.0%
Pulmonary Disease 11.1% $11,060,830 4.7% 1.8% - 20.4% 11.0% 0.0%
Neurology 13.4% $10,433,505 5.6% 2.5% - 24.3% 37.5% 0.0%
General Surgery 7.9% $8,054,942 3.5% 1.0% - 14.8% 36.8% 0.0%
Orthopedic Surgery 4.4% $7,629,502 2.7% ( 1.0%) - 9.7% 9.1% 0.0%
Urology 3.9% $4,599,549 2.9% ( 1.7%) - 9.6% 12.1% 0.0%
Podiatry 8.3% $4,464,130 3.2% 2.0% - 14.7% 25.6% 0.0%
Emergency Medicine 3.6% $4,313,009 1.8% 0.1% - 7.1% 4.3% 0.0%
Gastroenterology 4.7% $4,211,116 2.5% ( 0.2%) - 9.7% 29.2% 0.0%
Hematology/Oncology 3.3% $3,273,890 1.9% ( 0.4%) - 7.0% 43.5% 0.0%
Nephrology 3.4% $3,036,448 2.4% ( 1.3%) - 8.1% 21.3% 0.0%
Ophthalmology 0.9% $2,246,893 0.5% ( 0.1%) - 1.9% 2.6% 0.0%
Clinical Laboratory (Billing Independently) 0.7% $915,752 0.6% ( 0.6%) - 1.9% 6.4% 0.0%
Dermatology 0.3% $278,140 0.3% ( 0.3%) - 0.8% 0.4% 0.0%
Diagnostic Radiology 0.1% $210,475 0.1% ( 0.1%) - 0.3% 9.9% 0.0%
All Provider Types 4.4% $180,088,478 0.5% 3.4% - 5.4% 17.3% 0.0%

C1g: First Coast Service Options FL 00590

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Carrier Provider Type Paid Claims Error Rate Provider Compliance Error Rate No Resolution Rate
Paid Error Rate Projected Improper Payments Standard Error 95% Confidence Interval
All Provider Types With Less Than 30 Claims 11.7% $243,955,226 5.8% 0.3% - 23.1% 17.2% 0.0%
General Practice 68.1% $197,084,747 9.5% 49.5% - 86.7% 79.9% 0.0%
Internal Medicine 17.0% $129,747,109 5.8% 5.6% - 28.4% 28.0% 0.0%
Cardiology 6.9% $50,646,887 3.0% 1.2% - 12.7% 19.2% 0.0%
Orthopedic Surgery 8.6% $22,541,237 2.9% 2.9% - 14.3% 42.7% 0.0%
General Surgery 11.0% $20,288,337 7.0% ( 2.7%) - 24.7% 42.0% 0.0%
Family Practice 5.7% $20,264,273 1.7% 2.4% - 8.9% 14.5% 0.0%
Gastroenterology 14.8% $17,972,373 4.2% 6.5% - 23.1% 23.4% 0.0%
Diagnostic Radiology 3.5% $11,862,160 1.7% 0.2% - 6.8% 7.6% 0.0%
Nurse Practitioner 22.2% $10,438,850 10.2% 2.3% - 42.2% 45.8% 0.0%
Clinical Laboratory (Billing Independently) 2.7% $10,401,509 1.4% 0.1% - 5.4% 9.6% 0.0%
Neurology 10.4% $8,935,672 4.0% 2.7% - 18.2% 34.5% 0.0%
Pulmonary Disease 4.1% $7,876,229 1.5% 1.1% - 7.1% 5.6% 0.0%
Independent Diagnostic Testing Facility (IDTF) 1.9% $5,497,822 1.7% ( 1.5%) - 5.3% 14.2% 0.0%
Ophthalmology 1.4% $4,691,674 0.7% ( 0.1%) - 2.8% 5.5% 0.0%
Psychiatry 6.6% $4,421,160 3.1% 0.5% - 12.7% 16.3% 0.0%
Hematology/Oncology 1.0% $4,315,983 0.4% 0.1% - 1.8% 2.5% 0.0%
Chiropractic 10.8% $4,310,590 4.1% 2.8% - 18.9% 39.9% 0.0%
Urology 2.0% $3,638,869 1.0% ( 0.0%) - 4.1% 15.6% 0.0%
Podiatry 1.7% $2,359,114 0.8% 0.2% - 3.1% 10.4% 0.0%
Physical Therapist in Private Practice 1.3% $1,079,151 1.0% ( 0.7%) - 3.3% 11.4% 0.0%
Anesthesiology 0.7% $839,755 0.7% ( 0.7%) - 2.0% 9.5% 0.0%
Dermatology 0.2% $296,238 0.2% ( 0.1%) - 0.5% 3.7% 0.0%
Pathology 0.0% $0 0.0% 0.0% - 0.0% 27.4% 0.0%
All Provider Types 10.0% $783,464,966 1.9% 6.2% - 13.8% 21.2% 0.0%

C1h: First Coast Service Options CT 00591

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Carrier Provider Type Paid Claims Error Rate Provider Compliance Error Rate No Resolution Rate
Paid Error Rate Projected Improper Payments Standard Error 95% Confidence Interval
Internal Medicine 8.8% $12,485,604 1.6% 5.5% - 12.0% 17.8% 0.0%
All Provider Types With Less Than 30 Claims 3.7% $11,262,698 0.8% 2.2% - 5.3% 7.1% 0.0%
Cardiology 6.0% $4,801,001 1.9% 2.2% - 9.7% 10.6% 0.0%
Orthopedic Surgery 3.8% $1,789,758 1.7% 0.5% - 7.1% 8.7% 0.0%
Gastroenterology 9.9% $1,695,186 4.3% 1.4% - 18.4% 20.9% 0.0%
Family Practice 4.6% $1,363,974 1.8% 1.1% - 8.2% 9.4% 0.0%
Ambulance Service Supplier (e.g., private ambulance companies, funeral homes) 1.2% $1,148,502 1.1% ( 0.9%) - 3.3% 2.6% 0.0%
Hematology/Oncology 0.8% $781,956 0.5% ( 0.2%) - 1.8% 3.5% 0.0%
Nurse Practitioner 4.5% $595,129 2.0% 0.7% - 8.3% 14.8% 0.0%
Diagnostic Radiology 0.4% $361,806 0.3% ( 0.3%) - 1.1% 3.0% 0.0%
Ophthalmology 0.4% $333,055 0.3% ( 0.2%) - 0.9% 1.9% 0.0%
Podiatry 1.8% $326,947 1.2% ( 0.5%) - 4.1% 7.8% 0.0%
Physical Therapist in Private Practice 1.8% $298,460 1.8% ( 1.7%) - 5.3% 15.2% 0.0%
Psychiatry 1.2% $130,326 1.2% ( 1.1%) - 3.5% 16.8% 0.0%
Clinical Laboratory (Billing Independently) 0.1% $111,738 0.1% ( 0.1%) - 0.4% 1.2% 0.0%
Emergency Medicine 0.0% $0 0.0% 0.0% - 0.0% 8.5% 0.0%
Independent Diagnostic Testing Facility (IDTF) 0.0% $0 0.0% 0.0% - 0.0% 0.0% 0.0%
All Provider Types 3.2% $37,486,143 0.4% 2.5% - 3.9% 7.7% 0.0%

C1i: BCBS KS/NE/W MO 00650/00655/00651

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Carrier Provider Type Paid Claims Error Rate Provider Compliance Error Rate No Resolution Rate
Paid Error Rate Projected Improper Payments Standard Error 95% Confidence Interval
All Provider Types With Less Than 30 Claims 2.8% $18,930,664 0.6% 1.6% - 4.0% 9.2% 0.0%
Internal Medicine 7.3% $9,869,493 2.0% 3.4% - 11.1% 16.9% 0.0%
Cardiology 2.9% $4,099,636 1.1% 0.8% - 5.0% 4.2% 0.0%
Family Practice 4.0% $4,073,655 1.3% 1.5% - 6.4% 11.8% 0.4%
Diagnostic Radiology 4.0% $3,436,767 3.4% ( 2.7%) - 10.8% 11.7% 0.0%
Chiropractic 9.8% $2,782,241 2.8% 4.2% - 15.4% 22.2% 0.0%
Urology 2.8% $1,715,301 1.5% ( 0.1%) - 5.6% 3.6% 0.0%
Psychiatry 8.3% $1,328,449 3.9% 0.6% - 16.1% 8.9% 0.0%
Emergency Medicine 3.7% $1,019,465 2.1% ( 0.4%) - 7.9% 18.5% 0.0%
Orthopedic Surgery 1.4% $699,123 1.0% ( 0.6%) - 3.3% 9.5% 0.0%
Podiatry 3.1% $490,848 2.7% ( 2.2%) - 8.4% 24.7% 0.0%
Ophthalmology 0.3% $218,450 0.4% ( 0.3%) - 1.0% 3.6% 0.0%
Optometry 1.0% $212,908 1.0% ( 0.9%) - 2.8% 4.7% 0.0%
Clinical Laboratory (Billing Independently) 0.2% $84,686 0.2% ( 0.2%) - 0.6% 13.3% 0.0%
All Provider Types 3.3% $48,961,686 0.4% 2.5% - 4.2% 10.1% 0.0%

C1j: BCBS MT 00751

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Carrier Provider Type Paid Claims Error Rate Provider Compliance Error Rate No Resolution Rate
Paid Error Rate Projected Improper Payments Standard Error 95% Confidence Interval
All Provider Types With Less Than 30 Claims 1.6% $1,592,503 0.5% 0.6% - 2.5% 8.2% 0.0%
Internal Medicine 3.3% $447,520 0.9% 1.6% - 5.0% 9.9% 0.0%
Family Practice 4.4% $364,622 2.2% 0.1% - 8.6% 9.7% 0.0%
Chiropractic 8.7% $216,608 4.1% 0.6% - 16.7% 16.5% 0.0%
Cardiology 2.6% $193,127 1.4% ( 0.1%) - 5.3% 4.7% 0.0%
Optometry 5.6% $167,460 5.3% ( 4.9%) - 16.0% 4.5% 0.0%
Ophthalmology 1.5% $108,310 1.3% ( 1.1%) - 4.1% 10.2% 0.0%
Nurse Practitioner 3.3% $107,204 2.8% ( 2.1%) - 8.7% 8.6% 0.0%
Orthopedic Surgery 0.7% $73,138 0.5% ( 0.3%) - 1.7% 4.5% 0.0%
Physician Assistant 0.9% $24,926 0.9% ( 0.9%) - 2.6% 3.7% 0.0%
Clinical Laboratory (Billing Independently) 0.8% $9,176 0.8% ( 0.8%) - 2.3% 7.3% 0.0%
Diagnostic Radiology 0.0% $0 0.0% 0.0% - 0.0% 0.1% 0.0%
Podiatry 0.0% $0 0.0% 0.0% - 0.0% 17.9% 0.0%
All Provider Types 1.9% $3,304,593 0.4% 1.2% - 2.6% 7.7% 0.0%

C1k: HealthNow NY 00801

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Carrier Provider Type Paid Claims Error Rate Provider Compliance Error Rate No Resolution Rate
Paid Error Rate Projected Improper Payments Standard Error 95% Confidence Interval
Internal Medicine 10.4% $15,258,271 2.2% 6.1% - 14.7% 17.9% 0.0%
All Provider Types With Less Than 30 Claims 2.2% $10,561,599 0.6% 1.1% - 3.3% 11.9% 0.0%
Family Practice 5.6% $3,812,632 1.6% 2.5% - 8.7% 9.9% 0.0%
Cardiology 3.9% $3,487,296 1.4% 1.2% - 6.7% 8.2% 0.0%
General Surgery 10.9% $3,255,421 3.8% 3.4% - 18.4% 20.2% 0.0%
Orthopedic Surgery 4.9% $1,502,185 2.3% 0.4% - 9.5% 10.8% 0.0%
Ophthalmology 1.6% $1,178,908 0.8% 0.1% - 3.2% 3.3% 0.0%
Nurse Practitioner 5.3% $984,389 2.9% ( 0.4%) - 10.9% 11.8% 0.0%
Physician Assistant 5.1% $838,658 4.1% ( 2.9%) - 13.1% 16.6% 0.0%
Podiatry 3.5% $821,401 2.0% ( 0.4%) - 7.3% 11.8% 0.0%
Chiropractic 5.3% $649,891 2.9% ( 0.3%) - 10.9% 9.7% 0.0%
Emergency Medicine 2.3% $613,601 1.6% ( 0.9%) - 5.4% 8.2% 0.0%
Clinical Laboratory (Billing Independently) 2.4% $405,587 2.1% ( 1.7%) - 6.6% 10.9% 0.0%
Urology 0.2% $56,815 0.1% ( 0.1%) - 0.4% 1.5% 0.0%
Diagnostic Radiology 0.0% $21,093 0.0% ( 0.0%) - 0.0% 6.6% 0.0%
Physical Therapist in Private Practice 0.0% $0 0.0% 0.0% - 0.0% 9.2% 0.0%
All Provider Types 3.5% $43,447,746 0.4% 2.6% - 4.3% 10.9% 0.0%

C1l: Empire NY 00803

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Carrier Provider Type Paid Claims Error Rate Provider Compliance Error Rate No Resolution Rate
Paid Error Rate Projected Improper Payments Standard Error 95% Confidence Interval
All Provider Types With Less Than 30 Claims 4.7% $66,804,746 1.0% 2.6% - 6.7% 13.4% 0.0%
Internal Medicine 10.2% $44,564,564 2.2% 5.8% - 14.5% 24.0% 0.0%
Physical Therapist in Private Practice 20.4% $24,294,691 5.6% 9.4% - 31.4% 29.7% 0.0%
Pulmonary Disease 14.6% $17,056,993 4.7% 5.4% - 23.9% 25.9% 0.0%
Physical Medicine and Rehabilitation 24.5% $16,948,715 11.2% 2.6% - 46.4% 28.4% 0.0%
Cardiology 6.2% $15,691,553 2.0% 2.4% - 10.0% 16.1% 0.0%
Orthopedic Surgery 9.5% $10,581,911 4.3% 1.0% - 17.9% 14.2% 0.0%
Ophthalmology 4.0% $10,286,263 1.6% 0.9% - 7.2% 8.4% 0.0%
Diagnostic Radiology 4.7% $10,024,907 3.2% ( 1.5%) - 10.9% 25.0% 0.0%
Gastroenterology 7.0% $9,543,202 4.3% ( 1.3%) - 15.4% 13.8% 0.0%
Urology 7.5% $7,491,173 3.5% 0.7% - 14.3% 12.5% 0.0%
Family Practice 7.6% $6,663,474 3.4% 0.9% - 14.3% 18.8% 0.0%
Podiatry 3.9% $4,558,474 1.8% 0.4% - 7.4% 14.7% 0.0%
Psychiatry 6.5% $4,532,499 4.4% ( 2.1%) - 15.1% 18.6% 0.0%
Anesthesiology 3.9% $3,805,198 2.7% ( 1.5%) - 9.2% 12.3% 0.0%
Chiropractic 4.6% $861,408 2.6% ( 0.6%) - 9.7% 28.7% 0.0%
Clinical Laboratory (Billing Independently) 0.5% $857,614 0.3% ( 0.0%) - 1.0% 3.8% 0.0%
Dermatology 0.5% $676,081 0.4% ( 0.2%) - 1.2% 17.0% 0.0%
All Provider Types 6.5% $255,243,467 0.7% 5.1% - 7.8% 16.3% 0.0%

C1m: Empire NJ 00805

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Carrier Provider Type Paid Claims Error Rate Provider Compliance Error Rate No Resolution Rate
Paid Error Rate Projected Improper Payments Standard Error 95% Confidence Interval
All Provider Types With Less Than 30 Claims 8.1% $67,449,450 2.4% 3.4% - 12.9% 27.9% 0.0%
Cardiology 11.6% $37,747,664 3.1% 5.6% - 17.6% 67.3% 0.0%
Internal Medicine 9.1% $34,946,057 1.5% 6.1% - 12.1% 19.0% 0.0%
Hematology/Oncology 10.6% $14,026,599 4.1% 2.5% - 18.6% 9.3% 0.0%
Family Practice 11.5% $13,553,749 3.4% 4.9% - 18.1% 39.0% 0.0%
Orthopedic Surgery 8.6% $12,353,060 2.9% 3.0% - 14.2% 15.5% 0.0%
Gastroenterology 9.9% $8,591,050 3.6% 2.9% - 16.9% 27.7% 0.0%
Neurology 9.7% $8,125,329 3.5% 2.8% - 16.5% 13.3% 0.0%
Pulmonary Disease 10.1% $6,817,863 4.2% 1.8% - 18.4% 34.3% 0.0%
Physical Medicine and Rehabilitation 13.2% $6,757,271 5.3% 2.9% - 23.5% 26.4% 0.0%
Clinical Laboratory (Billing Independently) 2.3% $5,564,156 1.8% ( 1.2%) - 5.8% 11.4% 0.0%
Ambulance Service Supplier (e.g., private ambulance companies, funeral homes) 2.9% $3,931,903 2.9% ( 2.7%) - 8.5% 14.7% 0.0%
Physical Therapist in Private Practice 7.2% $3,234,805 4.9% ( 2.4%) - 16.8% 15.2% 0.0%
Urology 7.5% $2,888,781 2.9% 1.9% - 13.1% 17.6% 0.0%
Emergency Medicine 4.0% $2,338,707 2.7% ( 1.3%) - 9.2% 10.9% 0.0%
Chiropractic 6.7% $2,135,845 3.5% ( 0.1%) - 13.5% 22.1% 0.0%
Podiatry 3.0% $1,996,544 1.4% 0.2% - 5.8% 13.2% 0.0%
Ophthalmology 0.3% $761,847 0.3% ( 0.3%) - 1.0% 13.2% 0.0%
Diagnostic Radiology 0.4% $705,562 0.3% ( 0.3%) - 1.0% 11.6% 0.0%
Anesthesiology 1.2% $619,725 1.0% ( 0.7%) - 3.1% 7.4% 0.0%
All Provider Types 7.0% $234,545,967 0.8% 5.5% - 8.6% 29.2% 0.0%

C1n: Nordian ND/CO/WY/IA/SD 00820/00824/00825/00826/00889

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Carrier Provider Type Paid Claims Error Rate Provider Compliance Error Rate No Resolution Rate
Paid Error Rate Projected Improper Payments Standard Error 95% Confidence Interval
Ophthalmology 9.6% $13,847,062 8.7% ( 7.5%) - 26.6% 10.3% 0.0%
All Provider Types With Less Than 30 Claims 1.8% $12,851,013 0.5% 0.9% - 2.8% 7.1% 0.0%
Family Practice 7.4% $10,639,596 2.0% 3.5% - 11.4% 17.9% 0.0%
Internal Medicine 7.7% $9,570,325 2.0% 3.8% - 11.6% 15.1% 0.0%
Chiropractic 13.8% $4,182,327 5.3% 3.3% - 24.3% 22.4% 0.0%
Cardiology 3.2% $2,708,703 1.2% 0.8% - 5.5% 5.8% 0.0%
Physical Therapist in Private Practice 8.6% $2,141,438 5.1% ( 1.4%) - 18.6% 14.3% 0.0%
Diagnostic Radiology 1.9% $1,966,080 1.0% ( 0.1%) - 3.9% 7.4% 0.0%
Urology 2.3% $1,339,938 2.2% ( 2.0%) - 6.5% 17.5% 0.0%
Orthopedic Surgery 0.7% $847,234 0.6% ( 0.5%) - 1.8% 3.0% 0.0%
Podiatry 2.9% $751,871 1.8% ( 0.6%) - 6.3% 6.8% 0.0%
Physician Assistant 3.6% $489,894 2.5% ( 1.3%) - 8.4% 3.3% 0.0%
Clinical Laboratory (Billing Independently) 1.2% $428,022 0.9% ( 0.5%) - 2.9% 10.9% 0.0%
Optometry 0.8% $230,590 0.8% ( 0.8%) - 2.4% 15.4% 0.0%
Dermatology 0.3% $133,579 0.3% ( 0.3%) - 0.9% 6.4% 0.0%
All Provider Types 3.7% $62,127,673 0.9% 2.0% - 5.4% 9.4% 0.0%

C1o: Nordian AK/AZ/HI/NV/OR/WA 00831/00832/00833/00834/00835/00836

Sort This Table
Carrier Provider Type Paid Claims Error Rate Provider Compliance Error Rate No Resolution Rate
Paid Error Rate Projected Improper Payments Standard Error 95% Confidence Interval
Orthopedic Surgery 23.4% $31,258,402 16.3% ( 8.5%) - 55.4% 21.8% 0.0%
All Provider Types With Less Than 30 Claims 2.3% $23,045,282 0.5% 1.4% - 3.3% 13.4% 0.0%
Internal Medicine 5.3% $22,266,113 1.1% 3.1% - 7.5% 20.7% 0.0%
Cardiology 4.0% $13,206,384 1.3% 1.5% - 6.5% 19.0% 0.0%
Family Practice 6.0% $11,727,703 1.3% 3.4% - 8.6% 12.4% 0.0%
Clinical Laboratory (Billing Independently) 6.4% $8,168,998 3.7% ( 0.8%) - 13.6% 18.2% 0.0%
Physical Therapist in Private Practice 9.6% $6,828,304 7.0% ( 4.2%) - 23.3% 11.6% 0.0%
Chiropractic 12.7% $4,973,571 5.8% 1.4% - 24.0% 38.6% 0.0%
Pulmonary Disease 6.0% $4,391,743 4.1% ( 2.0%) - 14.0% 15.7% 0.0%
Hematology/Oncology 3.7% $2,969,466 2.7% ( 1.7%) - 9.1% 7.0% 0.0%
Diagnostic Radiology 1.0% $2,545,131 1.0% ( 0.9%) - 2.9% 7.5% 0.0%
Dermatology 1.8% $2,057,735 1.5% ( 1.3%) - 4.8% 5.8% 0.0%
Ophthalmology 0.8% $1,821,580 0.5% ( 0.2%) - 1.9% 6.7% 0.0%
Ambulance Service Supplier (e.g., private ambulance companies, funeral homes) 0.6% $1,792,139 0.6% ( 0.6%) - 1.8% 8.0% 0.0%
Podiatry 3.4% $1,700,046 1.7% 0.2% - 6.7% 9.3% 0.0%
Emergency Medicine 0.8% $683,045 0.8% ( 0.7%) - 2.3% 14.8% 0.0%
Nurse Practitioner 1.7% $505,966 1.5% ( 1.2%) - 4.6% 3.6% 0.0%
Urology 0.2% $184,507 0.2% ( 0.2%) - 0.7% 17.1% 0.0%
All Provider Types 3.9% $140,126,116 0.8% 2.3% - 5.5% 13.8% 0.0%

C1p: HGSA PA 00865

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Carrier Provider Type Paid Claims Error Rate Provider Compliance Error Rate No Resolution Rate
Paid Error Rate Projected Improper Payments Standard Error 95% Confidence Interval
All Provider Types With Less Than 30 Claims 3.2% $42,224,675 1.0% 1.2% - 5.1% 9.8% 0.0%
Internal Medicine 4.2% $12,207,804 1.1% 2.0% - 6.3% 11.2% 0.0%
Diagnostic Radiology 5.7% $10,196,812 4.9% ( 3.9%) - 15.3% 8.3% 0.0%
Cardiology 3.1% $7,166,637 1.3% 0.7% - 5.6% 15.1% 0.0%
Emergency Medicine 5.4% $4,036,622 2.2% 1.1% - 9.7% 5.5% 0.0%
Chiropractic 19.3% $3,874,127 14.4% ( 8.8%) - 47.5% 26.1% 0.0%
Family Practice 2.1% $3,723,636 0.7% 0.6% - 3.5% 14.5% 0.0%
Ophthalmology 1.5% $2,151,821 1.0% ( 0.4%) - 3.3% 5.6% 0.0%
Clinical Laboratory (Billing Independently) 1.7% $1,732,114 1.1% ( 0.6%) - 3.9% 9.3% 0.0%
Urology 2.8% $1,631,250 1.8% ( 0.8%) - 6.4% 7.8% 0.0%
Podiatry 2.3% $1,459,385 1.7% ( 1.1%) - 5.6% 8.8% 0.0%
Hematology/Oncology 1.5% $1,239,504 1.0% ( 0.4%) - 3.3% 3.9% 0.0%
Pulmonary Disease 1.3% $1,000,884 0.7% 0.0% - 2.6% 13.4% 0.0%
Orthopedic Surgery 2.0% $989,027 1.9% ( 1.7%) - 5.7% 9.8% 0.0%
Anesthesiology 0.0% $13,175 0.0% ( 0.0%) - 0.1% 11.3% 0.0%
Ambulance Service Supplier (e.g., private ambulance companies, funeral homes) 0.0% $0 0.0% 0.0% - 0.0% 18.6% 0.0%
All Provider Types 3.0% $93,647,474 0.6% 2.0% - 4.1% 10.7% 0.0%

C1q: BCBS AR RI 00524

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Carrier Provider Type Paid Claims Error Rate Provider Compliance Error Rate No Resolution Rate
Paid Error Rate Projected Improper Payments Standard Error 95% Confidence Interval
Internal Medicine 6.1% $2,436,008 1.4% 3.3% - 8.9% 11.8% 0.0%
All Provider Types With Less Than 30 Claims 3.2% $1,736,087 0.9% 1.4% - 4.9% 13.0% 0.0%
Ambulance Service Supplier (e.g., private ambulance companies, funeral homes) 3.7% $783,209 2.3% ( 0.8%) - 8.1% 18.5% 0.0%
Cardiology 4.1% $736,727 1.4% 1.5% - 6.8% 16.4% 0.0%
Psychiatry 22.9% $609,182 6.1% 10.9% - 34.8% 23.6% 0.0%
Family Practice 9.3% $401,840 3.9% 1.6% - 17.1% 19.0% 0.0%
Emergency Medicine 4.8% $340,446 2.1% 0.8% - 8.9% 17.5% 0.0%
Gastroenterology 6.3% $280,629 3.1% 0.1% - 12.5% 10.1% 0.0%
Physical Therapist in Private Practice 6.2% $270,461 2.7% 0.9% - 11.5% 20.2% 0.0%
General Surgery 5.4% $257,335 3.0% ( 0.6%) - 11.4% 19.5% 0.0%
Orthopedic Surgery 2.8% $202,462 1.8% ( 0.7%) - 6.4% 19.3% 0.0%
Diagnostic Radiology 1.2% $153,105 0.7% ( 0.2%) - 2.6% 19.5% 0.0%
Podiatry 2.5% $139,092 1.5% ( 0.4%) - 5.4% 11.2% 0.0%
Urology 2.1% $91,627 1.7% ( 1.3%) - 5.4% 13.4% 0.0%
Ophthalmology 0.4% $53,912 0.4% ( 0.4%) - 1.2% 10.8% 0.0%
Chiropractic 7.1% $50,830 6.8% ( 6.2%) - 20.4% 52.9% 0.0%
Physician Assistant 1.8% $31,821 1.8% ( 1.7%) - 5.3% 28.4% 0.0%
Dermatology 0.3% $9,740 0.3% ( 0.3%) - 0.9% 10.1% 0.0%
Clinical Laboratory (Billing Independently) 0.0% $0 0.0% 0.0% - 0.0% 20.5% 0.0%
Pathology 0.0% $0 0.0% 0.0% - 0.0% 8.2% 0.0%
All Provider Types 3.9% $8,584,513 0.5% 3.0% - 4.8% 15.4% 0.0%

C1r: Palmetto SC 00880

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Carrier Provider Type Paid Claims Error Rate Provider Compliance Error Rate No Resolution Rate
Paid Error Rate Projected Improper Payments Standard Error 95% Confidence Interval
All Provider Types With Less Than 30 Claims 2.9% $9,760,314 0.6% 1.7% - 4.1% 17.7% 0.2%
Family Practice 8.3% $7,976,946 3.2% 2.1% - 14.6% 14.0% 0.0%
Ambulance Service Supplier (e.g., private ambulance companies, funeral homes) 9.0% $7,897,389 3.9% 1.4% - 16.5% 20.3% 0.0%
Internal Medicine 5.0% $5,070,150 1.1% 2.8% - 7.1% 13.8% 0.0%
Cardiology 3.6% $3,495,867 1.2% 1.3% - 5.9% 8.8% 0.0%
Chiropractic 20.7% $1,568,131 6.0% 9.0% - 32.4% 25.5% 0.0%
Hematology/Oncology 1.6% $1,335,330 0.8% ( 0.0%) - 3.2% 17.8% 0.0%
Emergency Medicine 5.1% $1,300,671 2.4% 0.3% - 9.9% 15.1% 0.0%
Urology 4.1% $1,194,391 3.3% ( 2.4%) - 10.6% 9.0% 0.0%
Pulmonary Disease 7.3% $1,157,008 3.3% 0.8% - 13.7% 20.4% 0.0%
Ophthalmology 2.2% $1,085,481 1.2% ( 0.2%) - 4.5% 13.7% 0.0%
General Surgery 1.5% $575,357 1.0% ( 0.5%) - 3.5% 26.0% 0.0%
Orthopedic Surgery 1.1% $376,605 0.9% ( 0.7%) - 2.9% 9.4% 0.0%
Diagnostic Radiology 0.8% $355,330 0.8% ( 0.6%) - 2.3% 11.2% 0.0%
Dermatology 0.9% $300,429 0.5% ( 0.1%) - 1.9% 1.3% 0.0%
Podiatry 0.4% $40,483 0.4% ( 0.4%) - 1.1% 18.0% 0.0%
All Provider Types 4.0% $43,489,882 0.5% 3.0% - 5.0% 15.7% 0.0%

C1s: Palmetto OH/WV 00883/00884

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Carrier Provider Type Paid Claims Error Rate Provider Compliance Error Rate No Resolution Rate
Paid Error Rate Projected Improper Payments Standard Error 95% Confidence Interval
All Provider Types With Less Than 30 Claims 4.0% $36,807,708 0.8% 2.5% - 5.5% 10.0% 0.0%
Internal Medicine 7.3% $31,642,918 1.8% 3.7% - 10.8% 16.7% 0.0%
Cardiology 3.8% $13,232,961 1.5% 0.8% - 6.8% 13.9% 0.0%
Family Practice 5.4% $12,373,097 1.7% 2.0% - 8.7% 10.8% 0.0%
Orthopedic Surgery 10.3% $10,962,149 4.0% 2.5% - 18.2% 12.7% 0.0%
General Surgery 6.3% $7,787,762 3.6% ( 0.6%) - 13.3% 10.5% 0.0%
Ophthalmology 2.3% $4,641,252 1.1% 0.1% - 4.5% 6.8% 0.0%
General Practice 9.1% $2,287,802 4.8% ( 0.3%) - 18.5% 13.9% 0.0%
Emergency Medicine 1.9% $1,938,611 1.2% ( 0.5%) - 4.3% 9.2% 0.0%
Pathology 3.6% $1,843,107 3.6% ( 3.4%) - 10.7% 5.9% 0.0%
Podiatry 2.4% $1,579,523 1.2% 0.0% - 4.7% 10.1% 0.0%
Chiropractic 2.6% $523,209 2.0% ( 1.4%) - 6.6% 26.2% 0.0%
Dermatology 0.5% $500,281 0.5% ( 0.6%) - 1.6% 1.1% 0.0%
Diagnostic Radiology 0.1% $152,905 0.1% ( 0.1%) - 0.2% 6.6% 0.0%
Ambulance Service Supplier (e.g., private ambulance companies, funeral homes) 0.0% $0 0.0% 0.0% - 0.0% 7.5% 0.0%
Clinical Laboratory (Billing Independently) 0.0% $0 0.0% 0.0% - 0.0% 6.4% 0.0%
Psychiatry 0.0% $0 0.0% 0.0% - 0.0% 20.3% 0.0%
All Provider Types 3.9% $126,273,284 0.5% 3.0% - 4.8% 10.8% 0.0%

C1t: Trailblazer TX 00900

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Carrier Provider Type Paid Claims Error Rate Provider Compliance Error Rate No Resolution Rate
Paid Error Rate Projected Improper Payments Standard Error 95% Confidence Interval
All Provider Types With Less Than 30 Claims 3.1% $52,039,172 0.6% 1.9% - 4.3% 16.1% 0.0%
Internal Medicine 9.1% $42,898,826 1.7% 5.8% - 12.4% 21.9% 0.0%
Family Practice 9.7% $31,542,590 2.2% 5.4% - 13.9% 25.7% 0.0%
Gastroenterology 9.5% $13,171,251 3.0% 3.6% - 15.5% 16.7% 0.0%
Cardiology 2.8% $11,348,625 1.0% 0.9% - 4.7% 5.9% 0.0%
Ambulance Service Supplier (e.g., private ambulance companies, funeral homes) 4.0% $8,720,787 2.8% ( 1.5%) - 9.5% 8.1% 0.0%
Orthopedic Surgery 5.0% $7,770,494 3.1% ( 1.2%) - 11.1% 12.2% 0.0%
Emergency Medicine 7.4% $7,640,405 3.7% 0.1% - 14.7% 18.0% 0.0%
Clinical Laboratory (Billing Independently) 2.5% $5,405,832 1.2% 0.1% - 4.9% 9.2% 0.0%
Urology 5.3% $4,608,462 2.8% ( 0.2%) - 10.9% 16.7% 0.0%
Podiatry 5.8% $3,248,988 3.0% ( 0.1%) - 11.6% 44.6% 0.0%
Nurse Practitioner 8.7% $3,146,117 6.0% ( 3.0%) - 20.5% 20.9% 0.0%
Hematology/Oncology 0.3% $2,186,367 0.3% ( 0.3%) - 0.9% 3.4% 0.0%
Chiropractic 4.0% $1,073,924 3.1% ( 2.0%) - 10.1% 23.9% 0.0%
Ophthalmology 0.5% $949,601 0.3% ( 0.2%) - 1.1% 16.7% 0.0%
Diagnostic Radiology 0.0% $76,116 0.0% ( 0.0%) - 0.1% 14.8% 0.0%
Mass Immunization Roster Billers (Mass Immunizers have to roster bill assigned claims and can only bill for immunizations) 0.0% $0 0.0% 0.0% - 0.0% 8.2% 0.0%
All Provider Types 3.8% $195,827,556 0.4% 3.0% - 4.6% 14.8% 0.0%

C1u: Trailblazer MD/DE/DC/VA 00901/00902/00903/00904

Sort This Table
Carrier Provider Type Paid Claims Error Rate Provider Compliance Error Rate No Resolution Rate
Paid Error Rate Projected Improper Payments Standard Error 95% Confidence Interval
All Provider Types With Less Than 30 Claims 4.4% $36,471,136 1.0% 2.4% - 6.4% 13.9% 0.0%
Internal Medicine 6.1% $27,662,080 1.4% 3.3% - 8.8% 17.4% 0.0%
Cardiology 5.4% $14,424,576 2.3% 1.0% - 9.8% 8.7% 0.0%
Family Practice 6.7% $10,012,237 1.8% 3.1% - 10.3% 19.5% 0.0%
Ophthalmology 5.1% $9,634,310 2.5% 0.2% - 10.0% 23.1% 0.0%
Hematology/Oncology 4.7% $8,542,080 3.5% ( 2.2%) - 11.6% 14.4% 0.0%
Orthopedic Surgery 4.3% $7,196,953 1.9% 0.5% - 8.1% 8.2% 0.0%
Urology 4.2% $4,576,330 2.6% ( 1.0%) - 9.3% 6.4% 0.0%
Nephrology 3.6% $3,238,761 1.7% 0.4% - 6.9% 17.4% 0.0%
Pulmonary Disease 8.7% $2,734,972 5.5% ( 2.1%) - 19.6% 19.6% 0.0%
General Surgery 2.0% $2,099,768 1.4% ( 0.8%) - 4.7% 16.8% 0.0%
Emergency Medicine 2.9% $2,079,184 1.6% ( 0.2%) - 6.0% 18.2% 0.0%
Podiatry 4.1% $1,887,585 1.9% 0.3% - 7.9% 25.0% 0.0%
Nurse Practitioner 2.5% $1,672,686 2.1% ( 1.6%) - 6.5% 3.8% 0.0%
Dermatology 1.3% $772,827 1.0% ( 0.6%) - 3.2% 15.2% 0.0%
Physical Therapist in Private Practice 1.5% $767,560 1.1% ( 0.6%) - 3.6% 16.0% 0.0%
Diagnostic Radiology 0.1% $379,780 0.1% ( 0.1%) - 0.4% 10.6% 0.0%
Ambulance Service Supplier (e.g., private ambulance companies, funeral homes) 0.0% $77,381 0.0% ( 0.0%) - 0.1% 12.0% 0.0%
Clinical Laboratory (Billing Independently) 0.0% $27,559 0.0% ( 0.0%) - 0.1% 4.2% 0.0%
All Provider Types 3.9% $134,257,765 0.5% 3.0% - 4.9% 14.1% 0.0%

C1v: Noridian UT 00823

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Carrier Provider Type Paid Claims Error Rate Provider Compliance Error Rate No Resolution Rate
Paid Error Rate Projected Improper Payments Standard Error 95% Confidence Interval
All Provider Types With Less Than 30 Claims 3.4% $4,861,906 0.8% 1.8% - 5.0% 14.5% 0.0%
Cardiology 7.0% $1,500,930 3.0% 1.1% - 12.8% 20.3% 0.0%
Family Practice 5.3% $969,257 1.6% 2.1% - 8.4% 16.3% 0.0%
Internal Medicine 5.2% $901,975 1.9% 1.6% - 8.9% 40.9% 0.0%
Chiropractic 21.2% $578,634 7.6% 6.4% - 36.0% 51.0% 0.0%
Orthopedic Surgery 1.1% $354,745 0.7% ( 0.3%) - 2.4% 15.5% 0.0%
Emergency Medicine 3.0% $290,549 1.7% ( 0.3%) - 6.4% 14.9% 0.0%
Clinical Laboratory (Billing Independently) 2.5% $286,054 2.8% ( 3.0%) - 7.9% 7.2% 0.0%
Ophthalmology 1.6% $229,233 1.0% ( 0.4%) - 3.7% 12.1% 0.0%
Podiatry 5.4% $223,930 2.5% 0.5% - 10.3% 17.2% 0.0%
Dermatology 0.3% $53,176 0.3% ( 0.3%) - 0.9% 1.3% 0.0%
Diagnostic Radiology 0.1% $22,932 0.1% ( 0.1%) - 0.4% 11.3% 0.0%
All Provider Types 3.3% $10,273,321 0.5% 2.3% - 4.2% 16.3% 0.0%

C1w: Triple S, INC. PR/VI 00973/00974

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Carrier Provider Type Paid Claims Error Rate Provider Compliance Error Rate No Resolution Rate
Paid Error Rate Projected Improper Payments Standard Error 95% Confidence Interval
Internal Medicine 18.6% $8,129,692 2.5% 13.7% - 23.4% 27.9% 0.0%
Ambulance Service Supplier (e.g., private ambulance companies, funeral homes) 9.7% $7,745,269 2.9% 4.1% - 15.3% 20.4% 0.0%
All Provider Types With Less Than 30 Claims 9.4% $6,834,638 1.7% 6.1% - 12.7% 23.2% 0.0%
General Practice 16.3% $3,594,286 2.1% 12.0% - 20.5% 40.1% 0.0%
General Surgery 9.2% $1,911,360 2.9% 3.5% - 14.9% 32.8% 0.0%
Nephrology 11.7% $1,654,674 4.3% 3.3% - 20.2% 22.9% 0.0%
Cardiology 6.1% $1,492,604 1.8% 2.7% - 9.6% 20.5% 0.0%
Urology 15.8% $1,439,689 4.1% 7.7% - 23.9% 43.3% 0.0%
Hematology/Oncology 7.0% $1,076,360 3.3% 0.5% - 13.5% 18.5% 0.0%
Neurology 15.3% $1,009,961 5.5% 4.5% - 26.0% 36.3% 0.0%
Physical Medicine and Rehabilitation 12.8% $961,405 3.4% 6.2% - 19.5% 26.2% 0.0%
Pulmonary Disease 10.4% $734,292 5.1% 0.5% - 20.3% 13.0% 0.0%
Rheumatology 14.4% $713,750 5.1% 4.5% - 24.4% 22.1% 0.0%
Diagnostic Radiology 2.2% $613,582 0.8% 0.6% - 3.9% 14.6% 0.0%
Clinical Laboratory (Billing Independently) 2.8% $555,694 1.0% 1.0% - 4.7% 20.8% 0.0%
Gastroenterology 7.3% $521,625 3.9% ( 0.4%) - 15.0% 13.2% 0.0%
Ophthalmology 3.4% $486,897 1.7% 0.1% - 6.8% 25.3% 0.0%
Family Practice 5.0% $347,523 2.0% 1.2% - 8.9% 22.9% 0.0%
Podiatry 6.0% $165,569 3.9% ( 1.6%) - 13.6% 37.8% 0.0%
Pathology 0.0% $0 0.0% 0.0% - 0.0% 16.7% 0.0%
Psychiatry 0.0% $0 0.0% 0.0% - 0.0% 12.5% 0.0%
All Provider Types 9.7% $39,988,868 0.8% 8.1% - 11.2% 24.5% 0.0%

C1x: GHI NY 14330

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Carrier Provider Type Paid Claims Error Rate Provider Compliance Error Rate No Resolution Rate
Paid Error Rate Projected Improper Payments Standard Error 95% Confidence Interval
Internal Medicine 6.0% $5,207,869 0.9% 4.3% - 7.7% 26.2% 0.0%
All Provider Types With Less Than 30 Claims 3.7% $4,440,212 0.7% 2.3% - 5.2% 24.7% 0.0%
Physical Medicine and Rehabilitation 9.6% $1,876,090 3.6% 2.6% - 16.6% 16.1% 0.0%
Physical Therapist in Private Practice 12.8% $1,603,504 4.2% 4.6% - 21.0% 29.6% 0.0%
Family Practice 9.2% $1,386,400 4.4% 0.6% - 17.8% 20.0% 0.0%
Cardiology 2.9% $1,006,090 1.1% 0.8% - 5.0% 10.5% 0.0%
Ophthalmology 3.7% $838,894 1.9% ( 0.0%) - 7.4% 19.4% 0.0%
Diagnostic Radiology 1.8% $538,345 1.0% ( 0.2%) - 3.8% 29.4% 0.0%
Psychiatry 3.8% $353,754 2.7% ( 1.5%) - 9.2% 13.9% 0.0%
Podiatry 0.9% $152,559 0.7% ( 0.4%) - 2.2% 15.3% 0.0%
Clinical Laboratory (Billing Independently) 0.0% $0 0.0% 0.0% - 0.0% 21.5% 0.0%
All Provider Types 4.7% $17,403,719 0.5% 3.8% - 5.7% 22.9% 0.0%

C1y: NHIC CA 31140/31146

Sort This Table
Carrier Provider Type Paid Claims Error Rate Provider Compliance Error Rate No Resolution Rate
Paid Error Rate Projected Improper Payments Standard Error 95% Confidence Interval
All Provider Types With Less Than 30 Claims 3.9% $55,600,463 0.8% 2.2% - 5.5% 13.8% 0.0%
Internal Medicine 6.2% $42,830,339 1.3% 3.7% - 8.7% 16.3% 0.0%
Cardiology 5.4% $32,958,628 1.5% 2.4% - 8.4% 10.3% 0.0%
Family Practice 8.8% $28,538,949 2.0% 4.8% - 12.8% 20.1% 0.0%
Psychiatry 17.6% $23,095,983 5.9% 6.0% - 29.2% 22.0% 0.0%
Orthopedic Surgery 8.4% $22,321,287 2.7% 3.0% - 13.8% 13.9% 0.0%
Pulmonary Disease 10.7% $19,325,356 3.5% 3.9% - 17.6% 17.2% 0.0%
Urology 7.0% $19,158,124 4.7% ( 2.3%) - 16.3% 10.0% 0.0%
General Practice 9.4% $10,008,359 4.2% 1.2% - 17.6% 12.9% 0.0%
Physical Therapist in Private Practice 5.1% $8,091,801 2.3% 0.6% - 9.6% 13.8% 0.0%
Ambulance Service Supplier (e.g., private ambulance companies, funeral homes) 2.5% $7,838,815 2.5% ( 2.3%) - 7.3% 5.9% 0.0%
Nephrology 4.1% $5,615,204 1.6% 0.9% - 7.3% 10.5% 0.0%
Hematology/Oncology 1.2% $5,311,290 0.7% ( 0.1%) - 2.5% 9.3% 0.0%
Emergency Medicine 4.1% $5,109,558 2.0% 0.1% - 8.0% 18.8% 0.0%
Ophthalmology 1.0% $4,824,356 0.5% ( 0.1%) - 2.0% 14.6% 0.0%
Chiropractic 11.1% $3,759,839 6.2% ( 1.0%) - 23.2% 23.8% 0.0%
Podiatry 2.7% $3,672,968 2.2% ( 1.6%) - 7.1% 6.4% 0.0%
Dermatology 1.5% $3,276,617 1.0% ( 0.4%) - 3.4% 10.1% 0.0%
Diagnostic Radiology 0.2% $584,160 0.2% ( 0.2%) - 0.5% 3.3% 0.0%
Clinical Laboratory (Billing Independently) 0.1% $198,939 0.1% ( 0.1%) - 0.2% 4.5% 0.0%
All Provider Types 4.4% $302,121,034 0.4% 3.6% - 5.3% 12.5% 0.0%

C1z: NHIC ME/MA/NH/VT 31142/31143/31144/31145

Sort This Table
Carrier Provider Type Paid Claims Error Rate Provider Compliance Error Rate No Resolution Rate
Paid Error Rate Projected Improper Payments Standard Error 95% Confidence Interval
All Provider Types With Less Than 30 Claims 4.1% $28,915,730 1.3% 1.6% - 6.6% 9.4% 0.0%
Internal Medicine 4.8% $11,349,719 0.9% 3.0% - 6.6% 10.7% 0.0%
Ambulance Service Supplier (e.g., private ambulance companies, funeral homes) 3.3% $6,290,812 2.0% ( 0.7%) - 7.3% 10.1% 0.0%
Hematology/Oncology 8.1% $4,771,629 5.8% ( 3.3%) - 19.5% 15.8% 0.0%
Family Practice 6.0% $3,936,801 2.9% 0.4% - 11.6% 19.4% 0.0%
Cardiology 2.4% $3,687,774 1.0% 0.6% - 4.3% 8.0% 0.0%
Orthopedic Surgery 1.8% $3,410,637 0.8% 0.2% - 3.4% 18.6% 0.0%
General Surgery 2.4% $1,854,194 1.5% ( 0.6%) - 5.4% 4.8% 0.0%
Urology 2.5% $1,734,366 1.7% ( 0.7%) - 5.8% 3.9% 0.0%
Ophthalmology 0.9% $1,662,381 0.5% ( 0.1%) - 1.8% 5.3% 0.0%
Chiropractic 5.5% $1,165,541 2.5% 0.6% - 10.5% 20.5% 0.0%
Emergency Medicine 2.7% $1,104,139 1.7% ( 0.6%) - 6.0% 18.4% 0.0%
Psychiatry 2.2% $1,064,674 1.2% ( 0.2%) - 4.6% 4.8% 0.0%
Podiatry 2.7% $997,649 1.4% 0.0% - 5.4% 7.8% 0.0%
Pathology 3.0% $903,727 2.9% ( 2.6%) - 8.6% 3.0% 0.0%
Nurse Practitioner 2.9% $808,261 1.5% 0.0% - 5.8% 8.0% 0.0%
Physical Therapist in Private Practice 1.5% $484,935 1.1% ( 0.7%) - 3.7% 4.7% 0.0%
Diagnostic Radiology 0.3% $324,539 0.2% ( 0.1%) - 0.6% 6.9% 0.0%
Clinical Laboratory (Billing Independently) 0.0% $0 0.0% 0.0% - 0.0% 16.4% 0.0%
All Provider Types 3.2% $74,467,507 0.5% 2.2% - 4.1% 10.1% 0.0%

C2a: WPS WI/IL/MI/MN 00951/00952/00953/00954

Sort This Table
Carrier Provider Type Paid Claims Error Rate Provider Compliance Error Rate No Resolution Rate
Paid Error Rate Projected Improper Payments Standard Error 95% Confidence Interval
All Provider Types With Less Than 30 Claims 4.1% $88,371,965 0.9% 2.4% - 5.8% 17.9% 0.0%
Internal Medicine 6.9% $72,631,125 1.6% 3.8% - 10.1% 17.9% 0.0%
Family Practice 5.3% $23,961,046 1.4% 2.5% - 8.0% 11.1% 0.0%
Psychiatry 15.5% $16,233,905 4.2% 7.3% - 23.7% 29.0% 0.0%
Cardiology 2.4% $15,592,217 1.0% 0.5% - 4.3% 23.2% 0.0%
Emergency Medicine 7.3% $14,746,439 3.3% 0.9% - 13.7% 10.1% 0.0%
Chiropractic 12.2% $14,041,574 4.2% 4.0% - 20.4% 29.1% 0.0%
General Surgery 3.9% $10,958,608 2.1% ( 0.2%) - 8.0% 14.7% 0.0%
Urology 3.1% $7,598,020 1.9% ( 0.6%) - 6.7% 7.4% 0.0%
Neurology 4.8% $6,366,078 2.4% 0.1% - 9.5% 31.9% 0.0%
Orthopedic Surgery 1.7% $6,243,673 0.9% ( 0.1%) - 3.5% 4.1% 0.0%
Hematology/Oncology 1.1% $5,943,726 0.6% ( 0.1%) - 2.3% 4.6% 0.0%
Ophthalmology 1.1% $5,610,297 0.8% ( 0.4%) - 2.5% 8.7% 0.0%
Pathology 1.9% $2,475,956 1.9% ( 1.8%) - 5.7% 17.7% 0.0%
Ambulance Service Supplier (e.g., private ambulance companies, funeral homes) 0.4% $1,775,085 0.4% ( 0.4%) - 1.3% 1.3% 0.0%
Diagnostic Radiology 0.3% $1,328,048 0.2% ( 0.1%) - 0.6% 7.6% 0.0%
Clinical Laboratory (Billing Independently) 0.2% $297,896 0.2% ( 0.2%) - 0.6% 8.7% 0.0%
Podiatry 0.0% $0 0.0% 0.0% - 0.0% 14.3% 0.0%
All Provider Types 3.6% $294,175,659 0.4% 2.8% - 4.4% 14.1% 0.0%

C2b: Noridian AZ/MT/ND/SD/UT/WY Part B MAC Region 3 03102/03202/03302/03502

Sort This Table
Provider Type Paid Claims Error Rate Provider Compliance Error Rate No Resolution Rate
Paid Error Rate Projected Improper Payments Standard Error 95% Confidence Interval
All Provider Types With Less Than 30 Claims 6.5% $4,970,175 1.8% 3.0% - 10.0% 24.1% 0.0%
Internal Medicine 10.0% $2,300,443 2.9% 4.4% - 15.6% 17.7% 0.0%
Orthopedic Surgery 7.5% $541,871 3.9% ( 0.2%) - 15.3% 9.0% 0.0%
Cardiology 3.6% $532,884 1.9% ( 0.1%) - 7.2% 13.3% 0.0%
Family Practice 4.5% $517,055 2.2% 0.1% - 8.9% 22.7% 0.0%
Physical Therapist in Private Practice 11.7% $446,088 8.8% ( 5.5%) - 28.9% 20.0% 0.0%
Emergency Medicine 10.9% $375,570 6.9% ( 2.7%) - 24.4% 25.1% 0.0%
Chiropractic 16.0% $310,903 7.8% 0.7% - 31.4% 18.8% 0.0%
Ophthalmology 1.8% $211,808 1.8% ( 1.7%) - 5.4% 25.4% 0.0%
Diagnostic Radiology 1.0% $196,377 0.7% ( 0.4%) - 2.5% 3.4% 0.0%
Podiatry 4.5% $75,231 4.2% ( 3.7%) - 12.7% 28.6% 0.0%
Dermatology 0.7% $45,498 0.6% ( 0.5%) - 1.8% 10.1% 0.0%
Physician Assistant 0.2% $7,410 0.2% ( 0.2%) - 0.6% 29.9% 0.0%
Clinical Laboratory (Billing Independently) 0.0% $0 0.0% 0.0% - 0.0% 5.8% 0.0%
All Provider Types 5.5% $10,531,313 0.9% 3.8% - 7.3% 19.3% 0.0%


Appendix C: DME Contractors

C3a: AdminaStar Region B 00635

Sort This Table
DMERC Provider Type Paid Claims Error Rate Provider Compliance Error Rate No Resolution Rate
Paid Error Rate Projected Improper Payments Standard Error 95% Confidence Interval
Pharmacy 3.7% $16,390,997 0.9% 1.9% - 5.4% 10.3% 0.0%
All Provider Types With Less Than 30 Claims 8.1% $9,836,855 5.2% ( 2.0%) - 18.2% 16.5% 1.3%
Medical supply company not included in 51, 52, or 53 2.4% $7,816,092 0.8% 0.8% - 4.0% 13.4% 0.0%
Medical Supply Company with Respiratory Therapist 4.5% $4,934,664 2.7% ( 0.9%) - 9.8% 6.7% 0.0%
All Provider Types 3.9% $38,978,608 0.9% 2.2% - 5.5% 11.7% 0.1%

C3b: TriCenturion Region A 77011

Sort This Table
DMERC Provider Type Paid Claims Error Rate Provider Compliance Error Rate No Resolution Rate
Paid Error Rate Projected Improper Payments Standard Error 95% Confidence Interval
Pharmacy 5.4% $15,757,666 1.5% 2.4% - 8.3% 8.0% 0.0%
Medical supply company not included in 51, 52, or 53 2.2% $6,106,726 2.2% ( 2.1%) - 6.6% 11.0% 0.0%
All Provider Types With Less Than 30 Claims 7.7% $4,357,075 7.8% ( 7.7%) - 23.0% 8.5% 0.0%
Medical Supply Company with Respiratory Therapist 0.9% $879,882 0.8% ( 0.7%) - 2.4% 5.7% 0.0%
All Provider Types 3.7% $27,101,350 1.2% 1.3% - 6.1% 8.9% 0.0%

C3c: Palmetto Region C 00885

Sort This Table
DMERC Provider Type Paid Claims Error Rate Provider Compliance Error Rate No Resolution Rate
Paid Error Rate Projected Improper Payments Standard Error 95% Confidence Interval
Medical supply company not included in 51, 52, or 53 24.6% $457,174,964 3.9% 17.0% - 32.1% 34.5% 0.0%
Pharmacy 14.2% $234,773,430 3.4% 7.6% - 20.8% 24.7% 0.0%
All Provider Types With Less Than 30 Claims 12.8% $74,318,924 8.5% ( 3.9%) - 29.5% 15.3% 0.0%
Medical Supply Company with Respiratory Therapist 1.4% $3,759,429 0.9% ( 0.2%) - 3.1% 9.6% 0.0%
All Provider Types 17.7% $770,026,748 2.5% 12.8% - 22.5% 27.1% 0.0%

C3d: CIGNA Region D 05655

Sort This Table
DMERC Provider Type Paid Claims Error Rate Provider Compliance Error Rate No Resolution Rate
Paid Error Rate Projected Improper Payments Standard Error 95% Confidence Interval
Pharmacy 4.9% $25,772,197 1.9% 1.2% - 8.7% 11.6% 0.0%
Medical supply company not included in 51, 52, or 53 1.6% $10,111,641 0.6% 0.4% - 2.8% 11.4% 0.0%
Medical Supply Company with Respiratory Therapist 2.6% $2,420,150 1.8% ( 0.8%) - 6.1% 7.0% 0.0%
All Provider Types With Less Than 30 Claims 1.9% $2,132,448 1.4% ( 0.9%) - 4.6% 12.9% 0.0%
All Provider Types 3.0% $40,436,437 0.8% 1.3% - 4.6% 11.4% 0.0%

C3e: NHIC DME MAC Region A 16003

Sort This Table
Provider Type Paid Claims Error Rate Provider Compliance Error Rate No Resolution Rate
Paid Error Rate Projected Improper Payments Standard Error 95% Confidence Interval
Pharmacy 5.5% $17,774,412 1.2% 3.1% - 7.8% 14.2% 0.0%
Medical supply company not included in 51, 52, or 53 2.5% $6,284,021 0.9% 0.8% - 4.2% 9.1% 0.0%
Medical Supply Company with Respiratory Therapist 5.4% $6,024,122 1.8% 2.0% - 8.9% 10.0% 0.0%
All Provider Types With Less Than 30 Claims 3.3% $2,609,168 2.4% ( 1.3%) - 7.9% 13.6% 5.7%
All Provider Types 4.2% $32,691,723 0.7% 2.9% - 5.6% 11.9% 0.5%

C3f: National Government Services MAC DME Region B 17003

Sort This Table
Provider Type Paid Claims Error Rate Provider Compliance Error Rate No Resolution Rate
Paid Error Rate Projected Improper Payments Standard Error 95% Confidence Interval
Pharmacy 5.9% $29,751,624 0.9% 4.1% - 7.7% 12.3% 0.0%
Medical supply company not included in 51, 52, or 53 2.7% $10,689,269 0.7% 1.4% - 4.1% 9.3% 0.0%
All Provider Types With Less Than 30 Claims 2.8% $3,417,679 2.3% ( 1.8%) - 7.4% 6.7% 0.0%
Medical Supply Company with Respiratory Therapist 2.0% $2,685,219 0.9% 0.3% - 3.7% 10.4% 0.0%
Individual orthotic personnel certified by an accrediting organization 0.0% $0 0.0% 0.0% - 0.0% 8.1% 0.0%
All Provider Types 4.0% $46,543,790 0.5% 2.9% - 5.1% 10.4% 0.0%

C3g: Noridian Administrative Services DME MAC Region D 19003

Sort This Table
Provider Type Paid Claims Error Rate Provider Compliance Error Rate No Resolution Rate
Paid Error Rate Projected Improper Payments Standard Error 95% Confidence Interval
Medical supply company not included in 51, 52, or 53 14.5% $36,055,988 5.2% 4.3% - 24.6% 23.2% 0.2%
Pharmacy 8.6% $14,469,402 2.5% 3.7% - 13.5% 14.8% 0.0%
All Provider Types With Less Than 30 Claims 12.7% $5,014,889 7.4% ( 1.8%) - 27.1% 19.9% 7.9%
Medical Supply Company with Respiratory Therapist 9.4% $4,313,551 5.1% ( 0.6%) - 19.5% 12.8% 0.0%
All Provider Types 11.9% $59,853,831 2.8% 6.3% - 17.5% 19.3% 0.7%


Appendix C: Part A Contractors

C4a: AdminaStar IN/IL/KY/OH 00130/00131/00160/00332

Sort This Table
FI Provider Type Paid Claims Error Rate No Resolution Rate
Paid Error Rate Projected Improper Payments Standard Error 95% Confidence Interval
SNF 1.2% $40,664,527 0.4% 0.3% - 2.1% 0.0%
OPPS, Laboratory (an FI), Ambulatory (Billing an FI) 1.1% $31,215,750 0.3% 0.4% - 1.7% 0.1%
Other FI Service Types 3.1% $12,512,532 1.4% 0.4% - 5.8% 0.0%
ESRD 0.2% $1,147,073 0.2% ( 0.2%) - 0.6% 0.0%
All Codes With Less Than 30 Lines 0.0% $0 . - . 0.0%
Non-PPS Hospital In-patient 0.0% $0 0.0% 0.0% - 0.0% 0.0%
RHCs 0.0% $0 0.0% 0.0% - 0.0% 0.0%
All Provider Types 1.1% $85,539,881 0.2% 0.6% - 1.6% 0.1%

C4b: Anthem ME/MA 00180/00181

Sort This Table
FI Provider Type Paid Claims Error Rate No Resolution Rate
Paid Error Rate Projected Improper Payments Standard Error 95% Confidence Interval
OPPS, Laboratory (an FI), Ambulatory (Billing an FI) 3.1% $28,947,337 1.5% 0.1% - 6.1% 0.2%
Hospice 2.7% $6,874,110 2.6% ( 2.5%) - 7.9% 0.0%
HHA 0.7% $5,893,270 0.7% ( 0.7%) - 2.2% 0.0%
SNF 1.7% $4,753,492 1.1% ( 0.4%) - 3.8% 0.0%
Other FI Service Types 0.9% $2,484,250 0.6% ( 0.3%) - 2.1% 0.0%
All Codes With Less Than 30 Lines 0.8% $1,110,654 0.4% ( 0.1%) - 1.6% 0.0%
RHCs 5.0% $575,224 3.4% ( 1.6%) - 11.6% 0.0%
All Provider Types 1.9% $50,638,337 0.6% 0.6% - 3.1% 0.2%

C4c: Anthem NH/VT 00270

Sort This Table
FI Provider Type Paid Claims Error Rate No Resolution Rate
Paid Error Rate Projected Improper Payments Standard Error 95% Confidence Interval
Other FI Service Types 18.4% $24,061,237 14.0% ( 9.1%) - 45.9% 0.2%
OPPS, Laboratory (an FI), Ambulatory (Billing an FI) 1.3% $2,362,238 0.4% 0.5% - 2.1% 0.0%
Non-PPS Hospital In-patient 1.4% $565,347 1.5% ( 1.5%) - 4.3% 0.0%
All Codes With Less Than 30 Lines 4.8% $368,780 3.0% ( 1.1%) - 10.6% 0.0%
SNF 0.4% $276,258 0.3% ( 0.3%) - 1.0% 0.0%
RHCs 0.0% $0 0.0% 0.0% - 0.0% 0.0%
All Provider Types 6.2% $27,633,859 4.7% ( 3.0%) - 15.5% 0.0%

C4d: Cahaba AL 00010

Sort This Table
FI Provider Type Paid Claims Error Rate No Resolution Rate
Paid Error Rate Projected Improper Payments Standard Error 95% Confidence Interval
OPPS, Laboratory (an FI), Ambulatory (Billing an FI) 1.2% $4,168,169 0.4% 0.3% - 2.0% 0.1%
SNF 0.3% $319,863 0.3% ( 0.3%) - 0.9% 0.0%
Other FI Service Types 0.3% $277,134 0.2% ( 0.1%) - 0.6% 0.7%
All Codes With Less Than 30 Lines 0.3% $30,533 0.3% ( 0.3%) - 0.9% 0.0%
RHCs 0.0% $0 0.0% 0.0% - 0.0% 0.0%
All Provider Types 0.8% $4,795,699 0.3% 0.3% - 1.4% 0.2%

C4e: BCBS AR AR 00020

Sort This Table
FI Provider Type Paid Claims Error Rate No Resolution Rate
Paid Error Rate Projected Improper Payments Standard Error 95% Confidence Interval
SNF 2.0% $1,941,606 0.9% 0.1% - 3.8% 0.0%
OPPS, Laboratory (an FI), Ambulatory (Billing an FI) 1.1% $1,883,499 0.3% 0.4% - 1.8% 0.0%
Other FI Service Types 0.8% $791,527 0.3% 0.2% - 1.5% 0.0%
Non-PPS Hospital In-patient 1.0% $435,002 0.9% ( 0.8%) - 2.8% 0.0%
RHCs 0.0% $0 0.0% 0.0% - 0.0% 0.0%
All Provider Types 1.2% $5,051,634 0.3% 0.7% - 1.8% 0.0%

C4f: BCBS AZ AZ 00030

Sort This Table
FI Provider Type Paid Claims Error Rate No Resolution Rate
Paid Error Rate Projected Improper Payments Standard Error 95% Confidence Interval
OPPS, Laboratory (an FI), Ambulatory (Billing an FI) 1.4% $1,676,610 0.5% 0.4% - 2.3% 0.0%
SNF 0.7% $438,373 0.5% ( 0.2%) - 1.6% 0.0%
Other FI Service Types 1.4% $116,619 1.2% ( 0.9%) - 3.8% 0.0%
All Codes With Less Than 30 Lines 0.1% $21,172 0.1% ( 0.0%) - 0.2% 0.0%
All Provider Types 1.0% $2,252,775 0.3% 0.4% - 1.6% 0.0%

C4g: First Coast Service Options FL 00090

Sort This Table
FI Provider Type Paid Claims Error Rate No Resolution Rate
Paid Error Rate Projected Improper Payments Standard Error 95% Confidence Interval
OPPS, Laboratory (an FI), Ambulatory (Billing an FI) 1.3% $15,328,842 0.4% 0.5% - 2.1% 0.1%
Other FI Service Types 4.2% $14,320,609 1.3% 1.6% - 6.8% 0.0%
SNF 0.7% $7,112,416 0.3% 0.0% - 1.3% 0.0%
ESRD 2.3% $4,060,272 2.2% ( 2.1%) - 6.6% 0.0%
All Codes With Less Than 30 Lines 1.1% $214,834 1.3% ( 1.5%) - 3.6% 0.0%
All Provider Types 1.5% $41,036,972 0.3% 0.9% - 2.1% 0.0%

C4h: BCBS GA GA 00101

Sort This Table
FI Provider Type Paid Claims Error Rate No Resolution Rate
Paid Error Rate Projected Improper Payments Standard Error 95% Confidence Interval
OPPS, Laboratory (an FI), Ambulatory (Billing an FI) 1.1% $7,012,251 0.3% 0.4% - 1.7% 0.0%
ESRD 0.4% $5,343,046 0.1% 0.1% - 0.7% 0.0%
Other FI Service Types 2.7% $1,567,001 0.9% 1.0% - 4.4% 0.0%
All Codes With Less Than 30 Lines 0.6% $517,754 0.5% ( 0.4%) - 1.6% 0.0%
RHCs 1.6% $118,416 1.6% ( 1.5%) - 4.7% 0.0%
Non-PPS Hospital In-patient 0.0% $0 0.0% 0.0% - 0.0% 0.0%
All Provider Types 0.6% $14,558,467 0.1% 0.4% - 0.9% 0.0%

C4i: Cahaba IA/SD 00011

Sort This Table
FI Provider Type Paid Claims Error Rate No Resolution Rate
Paid Error Rate Projected Improper Payments Standard Error 95% Confidence Interval
HHA 0.3% $6,568,921 0.2% ( 0.0%) - 0.6% 0.0%
Hospice 0.3% $3,264,077 0.2% ( 0.2%) - 0.7% 0.0%
OPPS, Laboratory (an FI), Ambulatory (Billing an FI) 0.5% $1,847,881 0.2% 0.2% - 0.8% 0.0%
Other FI Service Types 0.2% $569,145 0.1% 0.0% - 0.4% 0.3%
SNF 0.2% $367,755 0.1% ( 0.1%) - 0.5% 0.0%
All Codes With Less Than 30 Lines 0.1% $45,532 0.1% ( 0.1%) - 0.3% 0.0%
Non-PPS Hospital In-patient 0.0% $19,870 0.0% ( 0.0%) - 0.0% 0.0%
RHCs 0.0% $0 0.0% 0.0% - 0.0% 0.0%
All Provider Types 0.3% $12,683,181 0.1% 0.1% - 0.5% 0.1%

C5a: BCBS KS KS 00150

Sort This Table
FI Provider Type Paid Claims Error Rate No Resolution Rate
Paid Error Rate Projected Improper Payments Standard Error 95% Confidence Interval
OPPS, Laboratory (an FI), Ambulatory (Billing an FI) 1.6% $2,987,213 1.1% ( 0.5%) - 3.8% 0.0%
SNF 1.3% $1,015,759 0.7% ( 0.1%) - 2.7% 0.0%
Other FI Service Types 0.5% $465,603 0.2% 0.2% - 0.8% 0.5%
Non-PPS Hospital In-patient 0.0% $3,992 0.0% ( 0.0%) - 0.0% 0.0%
All Codes With Less Than 30 Lines 0.0% $1,697 0.0% ( 0.0%) - 0.0% 0.0%
RHCs 0.0% $0 0.0% 0.0% - 0.0% 0.0%
All Provider Types 0.9% $4,474,264 0.4% 0.1% - 1.7% 0.2%

C5b: TriSpan LA/MO/MS 00230

Sort This Table
FI Provider Type Paid Claims Error Rate No Resolution Rate
Paid Error Rate Projected Improper Payments Standard Error 95% Confidence Interval
OPPS, Laboratory (an FI), Ambulatory (Billing an FI) 5.4% $26,248,740 2.8% ( 0.1%) - 11.0% 0.0%
SNF 2.9% $18,052,653 1.1% 0.7% - 5.2% 0.0%
Other FI Service Types 1.3% $3,271,759 0.6% 0.2% - 2.5% 0.0%
ESRD 0.8% $1,123,791 0.6% ( 0.5%) - 2.0% 0.0%
Non-PPS Hospital In-patient 0.2% $352,097 0.2% ( 0.2%) - 0.5% 0.0%
RHCs 0.6% $154,851 0.6% ( 0.5%) - 1.6% 0.0%
All Provider Types 2.9% $49,203,890 0.9% 1.1% - 4.6% 0.0%

C5c: BCBS MT MT 00250

Sort This Table
FI Provider Type Paid Claims Error Rate No Resolution Rate
Paid Error Rate Projected Improper Payments Standard Error 95% Confidence Interval
OPPS, Laboratory (an FI), Ambulatory (Billing an FI) 0.7% $522,281 0.3% 0.2% - 1.3% 0.0%
SNF 0.8% $198,735 0.5% ( 0.2%) - 1.7% 0.0%
Other FI Service Types 0.4% $138,149 0.2% 0.0% - 0.7% 0.0%
All Codes With Less Than 30 Lines 0.0% $0 0.0% 0.0% - 0.0% 0.0%
Non-PPS Hospital In-patient 0.0% $0 0.0% 0.0% - 0.0% 0.0%
RHCs 0.0% $0 0.0% 0.0% - 0.0% 0.0%
All Provider Types 0.5% $859,165 0.1% 0.2% - 0.7% 0.0%

C5d: Palmetto NC 00382

Sort This Table
FI Provider Type Paid Claims Error Rate No Resolution Rate
Paid Error Rate Projected Improper Payments Standard Error 95% Confidence Interval
OPPS, Laboratory (an FI), Ambulatory (Billing an FI) 2.3% $17,859,286 0.9% 0.6% - 4.1% 0.1%
Other FI Service Types 2.4% $6,458,602 2.1% ( 1.7%) - 6.6% 0.0%
SNF 1.8% $5,820,820 1.6% ( 1.3%) - 4.9% 0.0%
ESRD 1.2% $1,974,565 1.0% ( 0.8%) - 3.2% 2.1%
All Codes With Less Than 30 Lines 0.0% $0 0.0% 0.0% - 0.0% 3.8%
Non-PPS Hospital In-patient 0.0% $0 0.0% 0.0% - 0.0% 0.0%
All Provider Types 2.0% $32,113,273 0.7% 0.8% - 3.3% 0.2%

C5e: BCBS NE NE 00260

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FI Provider Type Paid Claims Error Rate No Resolution Rate
Paid Error Rate Projected Improper Payments Standard Error 95% Confidence Interval
OPPS, Laboratory (an FI), Ambulatory (Billing an FI) 2.2% $1,880,969 1.3% ( 0.3%) - 4.7% 0.3%
Other FI Service Types 0.5% $339,146 0.2% 0.1% - 0.9% 0.0%
RHCs 0.7% $50,667 0.5% ( 0.3%) - 1.6% 0.0%
Non-PPS Hospital In-patient 0.0% $6,751 0.0% ( 0.0%) - 0.0% 1.8%
All Codes With Less Than 30 Lines 0.1% $5,176 0.1% ( 0.1%) - 0.2% 0.0%
SNF 0.0% $0 0.0% 0.0% - 0.0% 0.0%
All Provider Types 0.9% $2,282,710 0.4% 0.1% - 1.7% 0.2%

C5f: BCBS AR RI 00021

Sort This Table
FI Provider Type Paid Claims Error Rate No Resolution Rate
Paid Error Rate Projected Improper Payments Standard Error 95% Confidence Interval
OPPS, Laboratory (an FI), Ambulatory (Billing an FI) 1.4% $1,039,776 0.5% 0.5% - 2.3% 0.0%
SNF 1.9% $932,688 1.0% ( 0.0%) - 3.8% 0.0%
All Codes With Less Than 30 Lines 0.0% $0 0.0% 0.0% - 0.0% 0.0%
All Provider Types 1.3% $1,972,464 0.4% 0.5% - 2.0% 0.0%

C5g: Palmetto SC 00380

Sort This Table
FI Provider Type Paid Claims Error Rate No Resolution Rate
Paid Error Rate Projected Improper Payments Standard Error 95% Confidence Interval
HHA 1.3% $112,773,209 0.4% 0.6% - 2.0% 0.0%
Hospice 1.1% $58,684,322 0.5% 0.2% - 2.0% 0.2%
All Codes With Less Than 30 Lines 3.9% $9,600,269 3.5% ( 3.0%) - 10.8% 0.0%
OPPS, Laboratory (an FI), Ambulatory (Billing an FI) 1.5% $7,430,728 0.8% ( 0.1%) - 3.1% 0.0%
All Provider Types 1.3% $188,488,528 0.3% 0.8% - 1.8% 0.0%

C5h: BCBS WY WY 00460

Sort This Table
FI Provider Type Paid Claims Error Rate No Resolution Rate
Paid Error Rate Projected Improper Payments Standard Error 95% Confidence Interval
OPPS, Laboratory (an FI), Ambulatory (Billing an FI) 2.6% $361,054 1.0% 0.6% - 4.7% 0.0%
Other FI Service Types 1.6% $127,910 1.1% ( 0.5%) - 3.7% 0.0%
All Codes With Less Than 30 Lines 1.9% $40,076 1.4% ( 1.0%) - 4.7% 0.0%
Non-PPS Hospital In-patient 0.1% $10,502 0.1% ( 0.1%) - 0.2% 0.0%
RHCs 0.8% $1,758 0.6% ( 0.3%) - 2.0% 0.0%
All Provider Types 1.4% $541,300 0.5% 0.5% - 2.4% 0.0%

C5i: Highmark Medicare Services DC/MD 00366

Sort This Table
FI Provider Type Paid Claims Error Rate No Resolution Rate
Paid Error Rate Projected Improper Payments Standard Error 95% Confidence Interval
SNF 1.3% $33,926,418 0.4% 0.5% - 2.0% 0.0%
Non-PPS Hospital In-patient 2.3% $33,772,140 0.6% 1.1% - 3.6% 0.1%
OPPS, Laboratory (an FI), Ambulatory (Billing an FI) 9.6% $25,856,689 5.0% ( 0.3%) - 19.4% 0.0%
Other FI Service Types 1.7% $4,049,935 1.1% ( 0.5%) - 4.0% 0.0%
Free Standing Ambulatory Surgery 0.2% $788,627 0.1% ( 0.1%) - 0.5% 0.0%
All Codes With Less Than 30 Lines 0.4% $631,303 0.2% ( 0.1%) - 0.8% 0.0%
All Provider Types 1.9% $99,025,111 0.4% 1.1% - 2.6% 0.1%

C5j: COSVI PR/VI 57400

Sort This Table
FI Provider Type Paid Claims Error Rate No Resolution Rate
Paid Error Rate Projected Improper Payments Standard Error 95% Confidence Interval
OPPS, Laboratory (an FI), Ambulatory (Billing an FI) 3.4% $1,443,480 1.1% 1.2% - 5.5% 0.0%
ESRD 0.8% $84,256 0.4% 0.0% - 1.5% 0.0%
Non-PPS Hospital In-patient 0.3% $24,733 0.3% ( 0.2%) - 0.8% 0.0%
All Codes With Less Than 30 Lines 0.2% $20,528 0.2% ( 0.2%) - 0.7% 0.0%
All Provider Types 2.2% $1,572,998 0.7% 0.9% - 3.5% 0.0%

C6a: Empire CT/DE/NY 00308

Sort This Table
FI Provider Type Paid Claims Error Rate No Resolution Rate
Paid Error Rate Projected Improper Payments Standard Error 95% Confidence Interval
OPPS, Laboratory (an FI), Ambulatory (Billing an FI) 1.5% $28,227,131 0.4% 0.7% - 2.4% 0.1%
ESRD 1.3% $6,302,829 0.8% ( 0.4%) - 2.9% 0.0%
SNF 0.3% $4,349,643 0.1% ( 0.0%) - 0.5% 0.0%
Other FI Service Types 0.1% $867,968 0.1% ( 0.1%) - 0.4% 0.0%
All Codes With Less Than 30 Lines 0.0% $0 0.0% 0.0% - 0.0% 0.0%
All Provider Types 0.9% $39,747,571 0.2% 0.4% - 1.3% 0.0%

C6b: Chisholm OK 00340

Sort This Table
FI Provider Type Paid Claims Error Rate No Resolution Rate
Paid Error Rate Projected Improper Payments Standard Error 95% Confidence Interval
OPPS, Laboratory (an FI), Ambulatory (Billing an FI) 0.5% $904,613 0.2% 0.1% - 0.9% 1.1%
Other FI Service Types 0.3% $223,116 0.1% 0.1% - 0.5% 2.3%
All Codes With Less Than 30 Lines 1.0% $119,776 0.8% ( 0.6%) - 2.5% 0.0%
RHCs 3.3% $41,450 3.3% ( 3.1%) - 9.8% 0.0%
Non-PPS Hospital In-patient 0.0% $4,009 0.0% ( 0.0%) - 0.0% 1.3%
All Provider Types 0.4% $1,292,964 0.1% 0.2% - 0.7% 1.2%

C6c: Veritus PA 00363

Sort This Table
FI Provider Type Paid Claims Error Rate No Resolution Rate
Paid Error Rate Projected Improper Payments Standard Error 95% Confidence Interval
SNF 0.8% $7,502,688 0.4% 0.0% - 1.5% 0.0%
OPPS, Laboratory (an FI), Ambulatory (Billing an FI) 0.8% $6,909,569 0.2% 0.4% - 1.2% 0.2%
Other FI Service Types 0.6% $415,967 0.5% ( 0.4%) - 1.6% 0.0%
All Codes With Less Than 30 Lines 0.0% $0 0.0% 0.0% - 0.0% 0.0%
RHCs 0.0% $0 0.0% 0.0% - 0.0% 0.0%
All Provider Types 0.7% $14,828,224 0.2% 0.3% - 1.1% 0.2%

C6d: Mutual of Omaha (all states) 52280

Sort This Table
FI Provider Type Paid Claims Error Rate No Resolution Rate
Paid Error Rate Projected Improper Payments Standard Error 95% Confidence Interval
OPPS, Laboratory (an FI), Ambulatory (Billing an FI) 1.9% $74,241,541 0.5% 0.8% - 2.9% 0.1%
SNF 1.2% $53,943,810 0.4% 0.4% - 1.9% 0.4%
Other FI Service Types 1.4% $3,929,335 0.7% ( 0.0%) - 2.8% 0.0%
All Codes With Less Than 30 Lines 0.0% $24,652 0.0% ( 0.0%) - 0.0% 0.0%
RHCs 0.0% $0 0.0% 0.0% - 0.0% 0.0%
All Provider Types 1.4% $132,139,337 0.3% 0.8% - 2.0% 0.1%

C6e: Noridian MN/ND 00320/00321

Sort This Table
FI Provider Type Paid Claims Error Rate No Resolution Rate
Paid Error Rate Projected Improper Payments Standard Error 95% Confidence Interval
SNF 2.8% $6,395,909 1.9% ( 1.0%) - 6.5% 0.0%
OPPS, Laboratory (an FI), Ambulatory (Billing an FI) 1.0% $4,280,399 0.3% 0.3% - 1.6% 0.2%
Other FI Service Types 1.0% $1,511,501 0.6% ( 0.2%) - 2.2% 0.0%
RHCs 1.7% $193,422 1.7% ( 1.6%) - 5.1% 0.0%
All Codes With Less Than 30 Lines 0.0% $1,480 0.0% ( 0.0%) - 0.0% 0.0%
Non-PPS Hospital In-patient 0.0% $0 0.0% 0.0% - 0.0% 0.0%
All Provider Types 1.2% $12,382,711 0.5% 0.3% - 2.1% 0.1%

C6f: Noridian AK/WA 00322

Sort This Table
FI Provider Type Paid Claims Error Rate No Resolution Rate
Paid Error Rate Projected Improper Payments Standard Error 95% Confidence Interval
OPPS, Laboratory (an FI), Ambulatory (Billing an FI) 1.1% $3,098,703 0.5% 0.1% - 2.2% 0.0%
All Codes With Less Than 30 Lines 2.4% $2,302,342 1.6% ( 0.8%) - 5.6% 0.0%
Other FI Service Types 1.2% $1,648,477 0.7% ( 0.2%) - 2.7% 0.0%
Non-PPS Hospital In-patient 0.0% $0 0.0% 0.0% - 0.0% 0.0%
RHCs 0.0% $0 0.0% 0.0% - 0.0% 0.0%
All Provider Types 1.1% $7,049,521 0.4% 0.4% - 1.8% 0.0%

C6g: Noridian ID/OR/UT 00323/00325

Sort This Table
FI Provider Type Paid Claims Error Rate No Resolution Rate
Paid Error Rate Projected Improper Payments Standard Error 95% Confidence Interval
ESRD 13.2% $11,545,409 8.5% ( 3.4%) - 29.9% 0.0%
OPPS, Laboratory (an FI), Ambulatory (Billing an FI) 1.7% $7,196,210 0.8% 0.2% - 3.3% 0.0%
Other FI Service Types 0.6% $865,414 0.3% 0.1% - 1.2% 0.0%
SNF 0.5% $659,912 0.2% ( 0.0%) - 0.9% 0.0%
Non-PPS Hospital In-patient 0.0% $20,927 0.0% ( 0.0%) - 0.1% 0.0%
RHCs 0.0% $0 0.0% 0.0% - 0.0% 0.0%
All Provider Types 2.2% $20,287,872 1.0% 0.2% - 4.2% 0.0%

C6h: Riverbend NJ/TN 00390

Sort This Table
FI Provider Type Paid Claims Error Rate No Resolution Rate
Paid Error Rate Projected Improper Payments Standard Error 95% Confidence Interval
SNF 2.1% $33,260,479 1.3% ( 0.4%) - 4.6% 0.0%
OPPS, Laboratory (an FI), Ambulatory (Billing an FI) 1.3% $18,336,025 0.3% 0.6% - 2.0% 0.0%
RHCs 0.6% $1,208,159 0.3% 0.0% - 1.1% 0.0%
ESRD 0.1% $295,069 0.1% ( 0.0%) - 0.2% 0.0%
Other FI Service Types 0.5% $257,005 0.3% ( 0.1%) - 1.1% 0.0%
All Codes With Less Than 30 Lines 0.0% $0 0.0% 0.0% - 0.0% 0.0%
All Provider Types 1.5% $53,356,738 0.6% 0.4% - 2.6% 0.0%

C6i: Trailblazer CO/NM/TX 00400

Sort This Table
FI Provider Type Paid Claims Error Rate No Resolution Rate
Paid Error Rate Projected Improper Payments Standard Error 95% Confidence Interval
OPPS, Laboratory (an FI), Ambulatory (Billing an FI) 2.5% $35,573,372 0.8% 0.9% - 4.1% 0.8%
SNF 3.0% $19,771,630 1.8% ( 0.4%) - 6.5% 1.9%
Other FI Service Types 2.4% $10,030,616 1.7% ( 1.0%) - 5.8% 0.7%
ESRD 0.3% $5,067,299 0.1% 0.1% - 0.5% 0.5%
RHCs 0.9% $766,370 0.5% ( 0.1%) - 2.0% 0.0%
All Codes With Less Than 30 Lines 0.0% $0 0.0% 0.0% - 0.0% 0.0%
Non-PPS Hospital In-patient 0.0% $0 0.0% 0.0% - 0.0% 2.9%
All Provider Types 1.6% $71,209,287 0.4% 0.8% - 2.4% 0.7%

C6j: UGS AS/CA/GU/HI/NV/NMI 00454

Sort This Table
FI Provider Type Paid Claims Error Rate No Resolution Rate
Paid Error Rate Projected Improper Payments Standard Error 95% Confidence Interval
SNF 5.6% $96,325,627 3.2% ( 0.6%) - 11.8% 0.0%
ESRD 4.5% $41,682,419 3.0% ( 1.3%) - 10.4% 0.0%
OPPS, Laboratory (an FI), Ambulatory (Billing an FI) 2.5% $36,937,742 0.9% 0.7% - 4.2% 0.2%
Hospice 1.9% $21,600,383 1.1% ( 0.3%) - 4.2% 0.0%
HHA 1.7% $19,415,299 1.0% ( 0.3%) - 3.6% 0.0%
Other FI Service Types 5.2% $6,194,838 4.3% ( 3.2%) - 13.5% 2.8%
All Codes With Less Than 30 Lines 0.0% $0 0.0% 0.0% - 0.0% 0.0%
RHCs 0.0% $0 0.0% 0.0% - 0.0% 0.0%
All Provider Types 3.4% $222,156,308 1.0% 1.4% - 5.4% 0.3%

C7a: UGS WI/MI 00450/00452

Sort This Table
FI Provider Type Paid Claims Error Rate No Resolution Rate
Paid Error Rate Projected Improper Payments Standard Error 95% Confidence Interval
HHA 3.0% $58,991,763 2.1% ( 1.0%) - 7.0% 0.0%
OPPS, Laboratory (an FI), Ambulatory (Billing an FI) 0.7% $11,839,751 0.3% 0.2% - 1.2% 0.1%
SNF 0.7% $8,010,698 0.4% ( 0.1%) - 1.5% 0.0%
FQHC 1.5% $6,550,678 0.5% 0.5% - 2.6% 0.2%
Other FI Service Types 0.9% $3,740,937 0.4% 0.1% - 1.7% 0.0%
All Codes With Less Than 30 Lines 0.0% $52,346 0.0% ( 0.0%) - 0.1% 0.0%
Hospice 0.0% $0 0.0% 0.0% - 0.0% 0.0%
Non-PPS Hospital In-patient 0.0% $0 0.0% 0.0% - 0.0% 0.0%
All Provider Types 1.2% $89,186,173 0.6% 0.1% - 2.3% 0.1%

C7b: UGS VA/WV 00453

Sort This Table
FI Provider Type Paid Claims Error Rate No Resolution Rate
Paid Error Rate Projected Improper Payments Standard Error 95% Confidence Interval
OPPS, Laboratory (an FI), Ambulatory (Billing an FI) 1.4% $12,351,849 0.4% 0.7% - 2.1% 0.1%
SNF 0.7% $3,737,397 0.3% 0.1% - 1.3% 0.0%
Other FI Service Types 1.2% $862,486 0.7% ( 0.1%) - 2.4% 0.0%
All Codes With Less Than 30 Lines 0.0% $0 0.0% 0.0% - 0.0% 0.0%
RHCs 0.0% $0 0.0% 0.0% - 0.0% 0.0%
All Provider Types 1.1% $16,951,731 0.2% 0.6% - 1.6% 0.1%

C7c: Noridian Part A MAC Region 3 03001

Sort This Table
FI Provider Type Paid Claims Error Rate No Resolution Rate
Paid Error Rate Projected Improper Payments Standard Error 95% Confidence Interval
SNF 5.4% $2,483,356 2.3% 0.9% - 9.8% 0.0%
OPPS, Laboratory (an FI), Ambulatory (Billing an FI) 1.0% $1,399,011 0.3% 0.4% - 1.6% 0.1%
Other FI Service Types 1.0% $486,009 0.5% 0.1% - 2.0% 0.0%
ESRD 0.8% $98,339 0.4% ( 0.1%) - 1.6% 0.0%
Non-PPS Hospital In-patient 0.2% $83,464 0.2% ( 0.2%) - 0.7% 0.2%
RHCs 0.0% $0 0.0% 0.0% - 0.0% 0.0%
All Provider Types 1.6% $4,550,179 0.4% 0.8% - 2.4% 0.1%


APPENDIX D: NO DOCUMENTATION INFORMATION

The tables in this section of the appendix provide no documentation information. This section of the appendix provides rates for:

  • All No Documentation claims,
  • No Documentation claims with less than $100 billed, and
  • No Documentation claims with $100 or more billed.

The no documentation rates in the tables below are different than the no documentation rate elsewhere in the report and appendices. The rates in these tables are based on the ratio of the dollar value of medical records not received to the dollar value of medical records requested. The tables are sorted in descending order by the overall error rate.

 

D1a: Overall Rates for No Documentation

Carrier/DMERC/FI All Less than $100 $100 or more
Paid No Doc Rate 95% Confidence Interval Paid No Doc Rate Less Than $100 95% Confidence Interval Paid No Doc Rate Greater Than Or Equal To $100 95% Confidence Interval
All 0.8% 0.6% - 1.0% 0.5% 0.4% - 0.7% 0.9% 0.6% - 1.1%

D2a: Part B Contractor Rates for No Documentation

Sort This Table
Carrier Cluster All Less than $100 $100 or more
Paid No Doc Rate 95% Confidence Interval Paid No Doc Rate Less Than $100 95% Confidence Interval Paid No Doc Rate Greater Than Or Equal To $100 95% Confidence Interval
First Coast Service Options FL 00590 6.3% 2.4% - 10.1% 1.1% 0.5% - 1.7% 9.7% 3.6% - 15.9%
Triple S, Inc. PR/VI 00973/00974 0.7% 0.3% - 1.2% 0.8% 0.3% - 1.3% 0.7% ( 0.0%) - 1.4%
CIGNA NC 05535 0.6% 0.1% - 1.2% 0.8% 0.1% - 1.4% 0.5% ( 0.2%) - 1.2%
Empire NY 00803 0.6% 0.2% - 1.0% 1.0% 0.3% - 1.7% 0.4% ( 0.2%) - 0.9%
Trailblazer MD/DE/DC/VA 00901/00902/00903/00904 0.5% 0.1% - 0.9% 0.4% 0.1% - 0.7% 0.6% ( 0.0%) - 1.2%
WPS WI/IL/MI/MN 00951/00952/00953/00954 0.5% 0.1% - 0.9% 0.9% 0.1% - 1.7% 0.1% ( 0.1%) - 0.3%
Palmetto SC 00880 0.5% ( 0.0%) - 1.0% 0.0% ( 0.0%) - 0.0% 0.8% ( 0.0%) - 1.7%
Noridian AK/AZ/HI/NV/OR/WA 00831/00832/00833/00834/00835/00836 0.5% 0.1% - 0.8% 0.7% 0.2% - 1.2% 0.3% ( 0.0%) - 0.7%
HGSA PA 00865 0.5% ( 0.1%) - 1.1% 0.6% 0.1% - 1.1% 0.4% ( 0.4%) - 1.1%
Noridian MAC Region 3 03002 0.4% ( 0.1%) - 1.0% 0.9% ( 0.3%) - 2.2% 0.0% 0.0% - 0.0%
First Coast Service Options CT 00591 0.4% 0.1% - 0.7% 0.6% 0.2% - 1.1% 0.2% ( 0.1%) - 0.5%
Trailblazer TX 00900 0.4% 0.1% - 0.7% 0.6% 0.2% - 0.9% 0.3% ( 0.1%) - 0.7%
Palmetto OH/WV 00883/00884 0.3% 0.1% - 0.6% 0.4% 0.1% - 0.8% 0.2% ( 0.2%) - 0.7%
CIGNA TN 05440 0.3% ( 0.1%) - 0.7% 0.4% ( 0.1%) - 0.8% 0.3% ( 0.1%) - 0.7%
Cahaba AL/GA/MS 00510/00511/00512 0.3% 0.0% - 0.6% 0.4% 0.0% - 0.9% 0.2% ( 0.2%) - 0.6%
GHI NY 14330 0.3% 0.0% - 0.5% 0.5% 0.1% - 0.9% 0.1% ( 0.1%) - 0.3%
NHIC CA 31140/31146 0.3% 0.0% - 0.5% 0.2% 0.0% - 0.5% 0.3% ( 0.1%) - 0.7%
BCBS KS/NE/W MO 00650/00655/00651 0.3% 0.0% - 0.5% 0.4% 0.1% - 0.6% 0.2% ( 0.2%) - 0.5%
NHIC ME/MA/NH/VT 31142/31143/31144/31145 0.2% ( 0.1%) - 0.6% 0.2% ( 0.0%) - 0.5% 0.3% ( 0.1%) - 0.6%
Empire NJ 00805 0.2% 0.0% - 0.4% 0.3% 0.0% - 0.5% 0.2% ( 0.1%) - 0.5%
HealthNow NY 00801 0.2% 0.0% - 0.4% 0.5% 0.1% - 0.8% 0.0% 0.0% - 0.0%
Noridian ND/CO/WY/IA/SD 00820/00824/00825/00826/00889 0.2% ( 0.1%) - 0.4% 0.3% ( 0.0%) - 0.6% 0.1% ( 0.1%) - 0.3%
CIGNA ID 05130 0.1% ( 0.0%) - 0.2% 0.2% ( 0.0%) - 0.5% 0.0% 0.0% - 0.0%
BCBS AR AR/NM/OK/MO/LA 00520/00521/00522/00523/00528 0.1% ( 0.0%) - 0.2% 0.2% ( 0.0%) - 0.4% 0.0% 0.0% - 0.0%
BCBS AR RI 00524 0.1% ( 0.0%) - 0.1% 0.1% ( 0.0%) - 0.3% 0.0% 0.0% - 0.0%
AdminaStar IN/KY 00630/00660 0.1% ( 0.0%) - 0.1% 0.1% ( 0.1%) - 0.3% 0.0% 0.0% - 0.0%
BCBS MT 00751 0.1% ( 0.0%) - 0.2% 0.1% ( 0.1%) - 0.4% 0.0% 0.0% - 0.0%
Noridian UT 00823 0.0% ( 0.0%) - 0.1% 0.1% ( 0.0%) - 0.3% 0.0% 0.0% - 0.0%
Combined 1.0% 0.6% - 1.4% 0.6% 0.4% - 0.7% 1.3% 0.6% - 2.0%

D3a: DME Contractor Rates for No Documentation

Sort This Table
DMERC Cluster All Less than $100 $100 or more
Paid No Doc Rate 95% Confidence Interval Paid No Doc Rate Less Than $100 95% Confidence Interval Paid No Doc Rate Greater Than Or Equal To $100 95% Confidence Interval
Palmetto Region C 00885 12.0% 7.8% - 16.3% 1.6% 0.9% - 2.4% 14.1% 9.0% - 19.2%
Noridian Administrative Services MAC Region D 19003 6.4% 1.1% - 11.7% 1.3% 0.2% - 2.5% 7.8% 1.1% - 14.5%
National Government Services MAC Region B 17003 0.6% 0.0% - 1.1% 0.3% 0.0% - 0.5% 0.7% ( 0.0%) - 1.3%
CIGNA Region D 05655 0.5% 0.1% - 1.0% 0.7% ( 0.1%) - 1.5% 0.5% ( 0.0%) - 1.0%
NHIC MAC Region A 16003 0.5% 0.0% - 0.9% 0.8% 0.1% - 1.6% 0.4% ( 0.1%) - 0.9%
AdminaStar Region B 00635 0.4% ( 0.1%) - 0.9% 0.6% ( 0.3%) - 1.5% 0.3% ( 0.3%) - 0.9%
Tricenturion Region A 77011 0.0% 0.0% - 0.0% 0.0% 0.0% - 0.0% 0.0% 0.0% - 0.0%
Combined 5.8% 3.9% - 7.7% 1.0% 0.6% - 1.3% 7.0% 4.7% - 9.4%

D4a: Part A Rates for No Documentation

Sort This Table
FI Cluster All Less than $100 $100 or more
Paid No Doc Rate 95% Confidence Interval Paid No Doc Rate Less Than $100 95% Confidence Interval Paid No Doc Rate Greater Than Or Equal To $100 95% Confidence Interval
First Coast Service Options FL 00090 0.4% 0.0% - 0.7% 0.6% 0.1% - 1.2% 0.3% 0.0% - 0.7%
BCBS WY WY 00460 0.3% ( 0.2%) - 0.8% 0.4% ( 0.4%) - 1.2% 0.3% ( 0.2%) - 0.8%
BCBS AR RI 00021 0.3% ( 0.2%) - 0.7% 0.2% ( 0.2%) - 0.5% 0.3% ( 0.2%) - 0.7%
UGS AS/CA/GU/HI/NV/NMI 00454 0.2% ( 0.1%) - 0.5% 0.1% ( 0.1%) - 0.3% 0.2% ( 0.1%) - 0.5%
AdminaStar IN/IL/KY/OH 00130/00131/00160/00332 0.2% ( 0.0%) - 0.4% 0.2% ( 0.1%) - 0.4% 0.2% ( 0.1%) - 0.4%
BCBS AZ AZ 00030 0.2% ( 0.1%) - 0.4% 0.2% ( 0.2%) - 0.6% 0.2% ( 0.1%) - 0.4%
COSVI PR/VI 57400 0.2% 0.0% - 0.3% 0.4% 0.0% - 0.7% 0.1% 0.0% - 0.2%
Noridian MAC Region 3 03001 0.1% ( 0.0%) - 0.2% 0.1% ( 0.1%) - 0.3% 0.1% ( 0.0%) - 0.2%
Anthem ME/MA 00180/00181 0.1% ( 0.0%) - 0.2% 0.2% ( 0.1%) - 0.5% 0.1% ( 0.0%) - 0.2%
BCBS AR AR 00020 0.1% 0.0% - 0.2% 0.2% ( 0.1%) - 0.5% 0.1% 0.0% - 0.2%
Trispan LA/MO/MS 00230 0.1% ( 0.0%) - 0.2% 0.0% ( 0.0%) - 0.1% 0.1% ( 0.0%) - 0.2%
Anthem NH/VT 00270 0.1% ( 0.0%) - 0.1% 0.0% 0.0% - 0.0% 0.1% ( 0.0%) - 0.2%
BCBS KS KS 00150 0.1% ( 0.0%) - 0.1% 0.0% ( 0.0%) - 0.1% 0.1% ( 0.0%) - 0.1%
Riverbend NJ/TN 00390 0.1% 0.0% - 0.1% 0.2% ( 0.1%) - 0.5% 0.0% ( 0.0%) - 0.1%
Mutual of Omaha (all states) 52280 0.0% 0.0% - 0.1% 0.1% ( 0.0%) - 0.2% 0.0% 0.0% - 0.1%
Palmetto NC 00382 0.0% ( 0.0%) - 0.1% 0.2% ( 0.1%) - 0.5% 0.0% ( 0.0%) - 0.1%
Chisholm OK 00340 0.0% ( 0.0%) - 0.1% 0.1% ( 0.0%) - 0.2% 0.0% ( 0.0%) - 0.1%
BCBS GA GA 00101 0.0% ( 0.0%) - 0.1% 0.3% ( 0.1%) - 0.6% 0.0% ( 0.0%) - 0.1%
UGS WI/MI 00450/00452 0.0% ( 0.0%) - 0.1% 0.2% ( 0.1%) - 0.4% 0.0% ( 0.0%) - 0.1%
Trailblazer CO/NM/TX 00400 0.0% 0.0% - 0.0% 0.7% 0.1% - 1.2% 0.0% 0.0% - 0.0%
Highmark Medicare Services DC/MD 00366 0.0% ( 0.0%) - 0.1% 0.0% ( 0.0%) - 0.0% 0.0% ( 0.0%) - 0.1%
BCBS MT MT 00250 0.0% ( 0.0%) - 0.1% 0.3% ( 0.2%) - 0.8% 0.0% 0.0% - 0.0%
Noridian ID/OR/UT 00323/00325 0.0% 0.0% - 0.0% 0.2% ( 0.1%) - 0.4% 0.0% ( 0.0%) - 0.0%
Empire CT/DE/NY 00308 0.0% 0.0% - 0.0% 0.2% ( 0.1%) - 0.4% 0.0% ( 0.0%) - 0.0%
Veritus PA 00363 0.0% ( 0.0%) - 0.0% 0.0% 0.0% - 0.0% 0.0% ( 0.0%) - 0.0%
UGS VA/WV 00453 0.0% ( 0.0%) - 0.0% 0.0% ( 0.0%) - 0.0% 0.0% ( 0.0%) - 0.0%
Noridian AK/WA 00322 0.0% ( 0.0%) - 0.0% 0.2% ( 0.1%) - 0.5% 0.0% 0.0% - 0.0%
Cahaba AL 00010 0.0% ( 0.0%) - 0.0% 0.0% 0.0% - 0.0% 0.0% ( 0.0%) - 0.0%
Cahaba IA/SD 00011 0.0% ( 0.0%) - 0.0% 0.2% ( 0.2%) - 0.6% 0.0% ( 0.0%) - 0.0%
Noridian MN/ND 00320/00321 0.0% ( 0.0%) - 0.0% 0.1% ( 0.0%) - 0.2% 0.0% 0.0% - 0.0%
Palmetto SC 00380 0.0% 0.0% - 0.0% 0.0% 0.0% - 0.0% 0.0% 0.0% - 0.0%
BCBS NE NE 00260 0.0% 0.0% - 0.0% 0.0% 0.0% - 0.0% 0.0% 0.0% - 0.0%
Combined 0.1% 0.0% - 0.1% 0.2% 0.1% - 0.3% 0.1% 0.0% - 0.1%


Appendix D: Reasons for No Documentation Errors

Tables D5 through D7 present the percentage of projected dollars in error for each category of the Carrier/DMERC/FI no documentation error rate. No documentation issues are defined in the following six categories:

  1. Beneficiary Issue - This category included situations in which:
    • The provider indicated that no such patient exists, or
    • The provider indicated that although this patient exists, no such service was provided to the patient.
  2. Wrong Date of Service (DOS) - For this category, the provider indicated that they did not have a medical record for the date of service in the CERT request, but they do have a medical record for the same service just a few days before or after the service in question. The claim in question may be a duplicate claim.
  3. Medical Record Issue - This category includes instances where the provider responded to a CERT documentation request but did not provide a medical record to support payment of a claim. This category includes the following situations:
    • The provider indicated that another department within the provider organization is responsible for fulfilling documentation requests,
    • The provider indicated they have the medical record but refused to provide it without payment for copying/mailing charges,
    • The provider indicated that it is a HIPAA violation to supply the record,
    • The provider submitted a statement that the record was destroyed as a result of extenuating circumstances (e.g., fire, flood, explosion),
    • The provider indicated in writing that they did not provide a service to the beneficiary on the date indicated on the claim, and
    • The provider indicated they have the medical record but refuse to provide it for some
      other reason.
  4. Billing Provider Issue - This category contains the following reasons for no documentation:
    • The provider number has been deactivated,
    • The provider has gone out of business, or
    • The provider commented, but failed to produce a record.
  5. Third Party Record - This category contains situations in which the provider indicated that a different provider, a third party, has the relevant medical record.
  6. Did Not Respond - No response to any CERT documentation request.

CMS attributed no documentation to multiple factors, including the providers’ lack of familiarity with the CERT Review Contractor, concerns about compliance with the Health Insurance Portability and Accountability Act (HIPAA), and cases where documentation did not exist. In some instances, all of the documentation may be located at a third party. If providers fail to contact the third party or the third party fails to submit the documentation, CMS counted the claim as a no documentation error.

The first column in each table is the percent of total error due to no documentation. The second column contains the total number of no documentation claims. The other columns show the distribution of the no documentation rate (i.e., the last six columns add up to 100% of the error rate). The tables are sorted in descending order by the paid claims error rate for no documentation for clusters.

 

D5a: Type of No Documentation Errors for Part B Contractor

Sort This Table
Services Billed to Carriers Paid No Documentation Error Rate Services Billed to Carriers Type of No Documentation Error
Non-Response Beneficiary Issue Paid No Doc Rate Less Than $100 Wrong DOS Billing Provider Issue Third Party Record
First Coast Service Options FL 00590 6.3% 34 5.2% 0.7% 0.1% 0.0% 0.0% 0.2%
Triple S, Inc. PR/VI 00973/00974 0.7% 19 0.3% 0.4% 0.0% 0.0% 0.0% 0.0%
CIGNA NC 05535 0.6% 12 0.0% 0.5% 0.1% 0.0% 0.0% 0.0%
Empire NY 00803 0.6% 14 0.1% 0.5% 0.0% 0.0% 0.0% 0.0%
Trailblazer MD/DE/DC/VA 00901/00902/00903/00904 0.5% 13 0.0% 0.3% 0.2% 0.0% 0.0% 0.0%
WPS WI/IL/MI/MN 00951/00952/00953/00954 0.5% 16 0.0% 0.4% 0.1% 0.0% 0.0% 0.0%
Palmetto SC 00880 0.5% 5 0.0% 0.0% 0.0% 0.4% 0.0% 0.0%
Noridian AK/AZ/HI/NV/OR/WA 00831/00832/00833/00834/00835/00836 0.5% 10 0.0% 0.2% 0.0% 0.2% 0.0% 0.0%
HGSA PA 00865 0.5% 9 0.0% 0.5% 0.0% 0.0% 0.0% 0.0%
Noridian MAC Region 3 03002 0.4% 7 0.2% 0.0% 0.0% 0.0% 0.2% 0.0%
First Coast Service Options CT 00591 0.4% 13 0.2% 0.1% 0.1% 0.0% 0.0% 0.0%
Trailblazer TX 00900 0.4% 12 0.0% 0.2% 0.0% 0.1% 0.0% 0.0%
Palmetto OH/WV 00883/00884 0.3% 9 0.0% 0.3% 0.0% 0.0% 0.0% 0.0%
CIGNA TN 05440 0.3% 7 0.0% 0.1% 0.0% 0.2% 0.0% 0.0%
Cahaba AL/GA/MS 00510/00511/00512 0.3% 7 0.0% 0.3% 0.1% 0.0% 0.0% 0.0%
GHI NY 14330 0.3% 10 0.0% 0.3% 0.0% 0.0% 0.0% 0.0%
NHIC CA 31140/31146 0.3% 11 0.0% 0.3% 0.0% 0.0% 0.0% 0.0%
BCBS KS/NE/W MO 00650/00655/00651 0.3% 11 0.0% 0.1% 0.1% 0.0% 0.0% 0.0%
NHIC ME/MA/NH/VT 31142/31143/31144/31145 0.2% 7 0.0% 0.2% 0.0% 0.0% 0.0% 0.0%
Empire NJ 00805 0.2% 8 0.0% 0.2% 0.0% 0.0% 0.0% 0.0%
HealthNow NY 00801 0.2% 11 0.1% 0.1% 0.0% 0.0% 0.0% 0.0%
Noridian ND/CO/WY/IA/SD 00820/00824/00825/00826/00889 0.2% 7 0.0% 0.2% 0.0% 0.0% 0.0% 0.0%
CIGNA ID 05130 0.1% 4 0.0% 0.1% 0.0% 0.0% 0.0% 0.0%
BCBS AR AR/NM/OK/MO/LA 00520/00521/00522/00523/00528 0.1% 6 0.0% 0.1% 0.0% 0.0% 0.0% 0.0%
BCBS AR RI 00524 0.1% 4 0.0% 0.1% 0.0% 0.0% 0.0% 0.0%
AdminaStar IN/KY 00630/00660 0.1% 2 0.0% 0.1% 0.0% 0.0% 0.0% 0.0%
BCBS MT 00751 0.1% 2 0.0% 0.1% 0.0% 0.0% 0.0% 0.0%
Noridian UT 00823 0.0% 6 0.0% 0.0% 0.0% 0.0% 0.0% 0.0%
Combined 1.0% 276 0.6% 0.3% 0.0% 0.0% 0.0% 0.0%

D6a: Type of No Documentaiton Errors for DME Contractors

Sort This Table
Services Billed to DMERCs Paid No Documentation Error Rate Services Billed to DMERCs Type of No Documentation Error
Non-Response Beneficiary Issue Paid No Doc Rate Less Than $100 Wrong DOS Billing Provider Issue Third Party Record
Palmetto Region C 00885 12.0% 65 11.0% 1.0% 0.0% 0.0% 0.0% 0.0%
Noridian Administrative Services MAC Region D 19003 6.4% 13 5.9% 0.5% 0.0% 0.0% 0.0% 0.0%
National Government Services MAC Region B 17003 0.6% 11 0.1% 0.5% 0.0% 0.0% 0.0% 0.0%
CIGNA Region D 05655 0.5% 6 0.0% 0.4% 0.1% 0.1% 0.0% 0.0%
NHIC MAC Region A 16003 0.5% 10 0.1% 0.4% 0.0% 0.0% 0.0% 0.0%
AdminaStar Region B 00635 0.4% 3 0.0% 0.4% 0.0% 0.0% 0.0% 0.0%
Tricenturion Region A 77011 0.0% 0 0.0% 0.0% 0.0% 0.0% 0.0% 0.0%
Combined 5.8% 108 5.2% 0.6% 0.0% 0.0% 0.0% 0.0%

D7a: Type of No Documentaiton Errors for Part A

Sort This Table
Services Billed to FIs Paid No Documentation Error Rate Services Billed to FIs Type of No Documentation Error
Non-Response Beneficiary Issue Paid No Doc Rate Less Than $100 Wrong DOS Billing Provider Issue Third Party Record
First Coast Service Options FL 00090 0.4% 13 0.1% 0.2% 0.0% 0.0% 0.0% 0.0%
BCBS WY WY 00460 0.3% 5 0.0% 0.3% 0.0% 0.0% 0.0% 0.0%
BCBS AR RI 00021 0.3% 6 0.0% 0.3% 0.0% 0.0% 0.0% 0.0%
UGS AS/CA/GU/HI/NV/NMI 00454 0.2% 5 0.1% 0.0% 0.0% 0.1% 0.0% 0.0%
AdminaStar IN/IL/KY/OH 00130/00131/00160/00332 0.2% 9 0.0% 0.2% 0.0% 0.0% 0.0% 0.0%
BCBS AZ AZ 00030 0.2% 7 0.0% 0.0% 0.1% 0.0% 0.0% 0.0%
COSVI PR/VI 57400 0.2% 16 0.0% 0.1% 0.0% 0.0% 0.0% 0.0%
Noridian MAC Region 3 03001 0.1% 11 0.0% 0.0% 0.0% 0.1% 0.0% 0.0%
Anthem ME/MA 00180/00181 0.1% 4 0.0% 0.1% 0.0% 0.0% 0.0% 0.0%
BCBS AR AR 00020 0.1% 11 0.0% 0.1% 0.0% 0.0% 0.0% 0.0%
Trispan LA/MO/MS 00230 0.1% 8 0.0% 0.1% 0.0% 0.0% 0.0% 0.0%
Anthem NH/VT 00270 0.1% 6 0.0% 0.1% 0.0% 0.0% 0.0% 0.0%
BCBS KS KS 00150 0.1% 4 0.0% 0.1% 0.0% 0.0% 0.0% 0.0%
Riverbend NJ/TN 00390 0.1% 6 0.0% 0.0% 0.0% 0.0% 0.0% 0.0%
Mutual of Omaha (all states) 52280 0.0% 7 0.0% 0.0% 0.0% 0.0% 0.0% 0.0%
Palmetto NC 00382 0.0% 10 0.0% 0.0% 0.0% 0.0% 0.0% 0.0%
Chisholm OK 00340 0.0% 8 0.0% 0.0% 0.0% 0.0% 0.0% 0.0%
BCBS GA GA 00101 0.0% 5 0.0% 0.0% 0.0% 0.0% 0.0% 0.0%
UGS WI/MI 00450/00452 0.0% 5 0.0% 0.0% 0.0% 0.0% 0.0% 0.0%
Trailblazer CO/NM/TX 00400 0.0% 7 0.0% 0.0% 0.0% 0.0% 0.0% 0.0%
Highmark Medicare Services DC/MD 00366 0.0% 5 0.0% 0.0% 0.0% 0.0% 0.0% 0.0%
BCBS MT MT 00250 0.0% 2 0.0% 0.0% 0.0% 0.0% 0.0% 0.0%
Noridian ID/OR/UT 00323/00325 0.0% 8 0.0% 0.0% 0.0% 0.0% 0.0% 0.0%
Empire CT/DE/NY 00308 0.0% 6 0.0% 0.0% 0.0% 0.0% 0.0% 0.0%
Veritus PA 00363 0.0% 2 0.0% 0.0% 0.0% 0.0% 0.0% 0.0%
UGS VA/WV 00453 0.0% 5 0.0% 0.0% 0.0% 0.0% 0.0% 0.0%
Noridian AK/WA 00322 0.0% 3 0.0% 0.0% 0.0% 0.0% 0.0% 0.0%
Cahaba AL 00010 0.0% 2 0.0% 0.0% 0.0% 0.0% 0.0% 0.0%
Cahaba IA/SD 00011 0.0% 3 0.0% 0.0% 0.0% 0.0% 0.0% 0.0%
Noridian MN/ND 00320/00321 0.0% 2 0.0% 0.0% 0.0% 0.0% 0.0% 0.0%
Palmetto SC 00380 0.0% 0 0.0% 0.0% 0.0% 0.0% 0.0% 0.0%
BCBS NE NE 00260 0.0% 0 0.0% 0.0% 0.0% 0.0% 0.0% 0.0%
Combined 0.1% 191 0.0% 0.0% 0.0% 0.0% 0.0% 0.0%

 


APPENDIX E: CODING INFORMATION

The CMS has recognized problems with certain procedure codes. In a letter dated June 1, 2000, the CMS Administrator notified Medicare physicians that CPT codes 99233 and 99214 for evaluation and management (E&M) services had accounted for a significant proportion of the FY 1998 and FY 1999 coding errors. The Administrator noted that documentation for many of these services more appropriately supported CPT codes 99231 and 99212, respectively, and reminded providers to document the specific procedures performed. While other E&M codes also contribute significantly to the error rate, analysis indicates continuing problems with the listed procedure codes.


 

CPT code 99233, subsequent hospital care. The physician should typically spend 35 minutes with the patient and perform at least two of these key procedures: a detailed interval patient history, a detailed examination, and/or medical decision making of high complexity.


 

Table E1 summarizes data for this code.

E1a: Problem Code: CPT Code 99233

Fiscal Year Number of Lines Reviewed Number of Lines Questioned Percent of Lines in Error
1996 217 115 53.0%
1997 416 128 30.8%
1998 457 114 24.9%
1999 187 102 54.5%
2000 449 220 49.0%
2001 338 142 42.0%
2002 228 174 76.3%
2003 709 435 61.4%
2004 768 391 50.9%
2005 1,079 474 43.9%
2006 1,102 440 39.9%
2007 1,157 532 46.0%

 

CPT code 99214, office or other outpatient visit. The physician should typically spend 25 minutes face-to-face with the patient and perform at least two of the following procedures: a detailed patient history, a detailed examination, and/or medical decision making of moderate complexity.


 

Table E2 summarizes data for this code.

E2a: Problem Code: CPT Code 99214

Fiscal Year Number of Lines Reviewed Number of Lines Questioned Percent of Lines in Error
1996 140 54 38.6%
1997 234 86 36.8%
1998 168 63 37.5%
1999 143 81 56.6%
2000 191 71 37.2%
2001 214 67 31.3%
2002 104 24 23.1%
2003 2,798 687 24.6%
2004 3,250 589 18.1%
2005 4,436 648 14.6%
2006 4,491 609 13.6%
2007 4,287 602 14.0%

 

CPT code 99232, subsequent hospital care. For this billing code, the physician should typically spend 25 minutes at bedside with the patient and should perform at least two of the following key procedures: an expanded problem-focused interval patient history, an expanded problem-focused examination, and/or medical decision making of moderate complexity.


 

Table E3 summarizes data for this code.

E3a: Problem Code: CPT Code 99232

Fiscal Year Number of Lines Reviewed Number of Lines Questioned Percent of Lines in Error
1996 597 266 44.6%
1997 1,159 350 30.2%
1998 911 181 19.9%
1999 837 279 33.3%
2000 881 270 30.6%
2001 964 146 15.1%
2002 488 179 36.7%
2003 2,213 855 38.6%
2004 2,485 754 30.3%
2005 3,194 555 17.4%
2006 3,236 295 9.1%
2007 3,164 393 12.4%

 

The American Medical Association (AMA) developed the E&M codes that Medicare physicians use when submitting claims for payment. In 2003, there were 21 categories of E&M codes, including categories such as office or other outpatient service, consultations, emergency department services, and critical care services. Within each category of codes there is a range of three to five levels of HCPCS codes that determines the level of service and the level of payment. There are three key descriptors used to determine the appropriate HCPCS code: history, examination, and medical decision-making. There are four other components, including counseling, coordination of care, nature of presenting problem, and time that are contributory factors, but they are not used to determine the HCPCS code.

Table E4 lists all E&M codes with 2,000 or more claims in the CERT sample. The table provides information on the types of error found for each code. The table is sorted in descending order by error rate.

E4a: E&M Codes with more than 2,000 claims reviewed

Sort This Table
E&M Codes Paid Claims Error Rate Provider Compliance Error Rate No Resolution Rate
Paid Error Rate Projected Improper Payments Standard Error 95% Confidence Interval
99232 8.9% $231,351,879 0.9% 7.1% - 10.6% 18.7% 0.0%
99214 6.6% $266,640,974 0.4% 5.9% - 7.3% 13.0% 0.0%
99213 2.5% $108,851,454 0.2% 2.1% - 2.9% 9.4% 0.0%

 

Tables E5 through E7 lists for each contractor type the top twenty services (if available) with the highest dollars in error due to overcoding. All estimates in these tables are based on a minimum of 30 claims in the sample. Data in these tables are sorted by projected improper payments.

For most of the coding errors, the medical reviewers determined that providers submitted documentation that supported a lower code than the code submitted (in these cases, providers are said to have overcoded claims). However, for some of the coding errors, the medical reviewers determined that the documentation supported a higher code than the code the provider submitted(in these cases, the providers are said to have undercoded claims).

E5a: Services with Overcoding Errors: Part B

Sort This Table
Service Billed to Carrier (HCPCS) Overcoding Errors
Paid Error Rate Projected Improper Payments 95% Confidence Interval
Office/outpatient visit, est (99214) 5.7% $228,962,082 5.1% - 6.2%
Subsequent hospital care (99233) 15.8% $201,421,366 13.3% - 18.3%
Office consultation (99244) 16.6% $115,451,305 13.5% - 19.8%
Office/outpatient visit, est (99215) 16.0% $112,805,311 13.7% - 18.4%
Inpatient consultation (99254) 14.3% $105,362,727 11.8% - 16.9%
Initial hospital care (99223) 13.0% $97,268,646 10.2% - 15.9%
Inpatient consultation (99255) 18.9% $91,290,030 14.6% - 23.1%
Office consultation (99245) 18.8% $81,704,677 14.5% - 23.2%
Subsequent hospital care (99232) 3.1% $79,664,155 2.3% - 3.8%
Office/outpatient visit, new (99204) 21.2% $70,678,566 17.0% - 25.5%
Office/outpatient visit, new (99203) 9.9% $44,041,735 7.5% - 12.3%
Office consultation (99243) 8.9% $41,285,612 6.6% - 11.2%
Office/outpatient visit, est (99213) 0.9% $38,316,353 0.7% - 1.1%
Critical care, first hour (99291) 5.0% $36,458,731 0.2% - 9.9%
Emergency dept visit (99285) 4.3% $35,194,753 2.9% - 5.6%
Office/outpatient visit, new (99205) 24.7% $34,136,809 17.4% - 32.0%
Nursing fac care, subseq (99309) 11.2% $32,977,152 8.5% - 13.9%
Nursing fac care, subseq (99310) 26.3% $25,294,947 20.5% - 32.2%
Initial hospital care (99222) 7.5% $23,582,943 5.2% - 9.9%
Inpatient consultation (99253) 6.0% $14,422,101 3.4% - 8.6%
All Other Codes 0.3% $190,285,738 0.3% - 0.4%
Overall 2.3% $1,700,605,739 2.1% - 2.4%

E6a: Services with Overcoding Errors: DME

Sort This Table
Service Billed to DMERC (HCPCS) Overcoding Errors
Paid Error Rate Projected Improper Payments 95% Confidence Interval
Levalbuterol non-comp unit (J7614) 4.9% $17,539,696 0.9% - 8.8%
Blood glucose/reagent strips (A4253) 1.0% $10,356,710 0.5% - 1.5%
Budesonide non-comp unit (J7626) 2.1% $4,577,894 ( 1.9%) - 6.1%
Enteral feed supp pump per d (B4035) 2.2% $3,715,180 ( 1.3%) - 5.7%
Oxygen concentrator (E1390) 0.2% $3,136,044 ( 0.0%) - 0.4%
EF complet w/intact nutrient (B4150) 3.0% $2,893,757 ( 2.8%) - 8.7%
High strength ltwt whlchr (K0004) 2.8% $1,973,524 0.1% - 5.5%
Multi den insert custom mold (A5513) 4.5% $1,898,139 ( 4.1%) - 13.0%
Albuterol ipratrop non-comp (J7620) 0.8% $1,681,045 ( 0.8%) - 2.5%
Lancets per box (A4259) 1.1% $1,251,402 0.5% - 1.8%
EF calorie dense>/=1.5Kcal (B4152) 2.0% $1,050,723 ( 0.7%) - 4.8%
Lightweight wheelchair (K0003) 1.6% $977,215 0.1% - 3.0%
Portable gaseous 02 (E0431) 0.1% $266,504 ( 0.1%) - 0.3%
Albuterol non-comp unit (J7613) 0.7% $258,637 ( 0.2%) - 1.6%
Iv pole (E0776) 2.5% $207,975 ( 2.4%) - 7.4%
Lithium batt for glucose mon (A4235) 5.0% $58,017 ( 4.4%) - 14.3%
Ipratropium bromide non-comp (J7644) 0.4% $54,139 ( 0.4%) - 1.2%
Hosp bed semi-electr w/ matt (E0260) 0.0% $46,118 ( 0.0%) - 0.1%
Nebulizer administration set (A7003) 0.7% $38,033 ( 0.6%) - 1.9%
Mycophenolate mofetil oral (J7517) 0.0% $1,497 ( 0.0%) - 0.0%
All Other Codes 0.2% $8,085,506 0.0% - 0.3%
Overall 0.6% $60,067,754 0.3% - 0.9%

E7a: Services with Overcoding Errors: Part A

Sort This Table
Type Of Bill Overcoding Errors
Paid Error Rate Projected Improper Payments 95% Confidence Interval
SNF-inpatient (including Part A) (21) 1.0% $216,671,103 0.4% - 1.6%
Hospital-outpatient (HHA-A also)(under OPPS 13X must be used for ASC claims submitted for OPPS payment -- eff. 7/00) (13) 0.4% $88,466,021 0.2% - 0.5%
Special facility or ASC surgery-rural primary care hospital (eff 10/94) (85) 1.4% $36,475,588 ( 0.2%) - 3.1%
HHA-outpatient (HHA-A also) (33) 0.4% $25,989,837 ( 0.2%) - 1.1%
Clinic-hospital based or independent renal dialysis facility (72) 0.4% $25,370,225 0.1% - 0.6%
HHA-inpatient or home health visits (Part B only) (32) 0.3% $23,675,687 0.1% - 0.5%
Special facility or ASC surgery-hospice (non-hospital based) (81) 0.2% $13,921,897 ( 0.1%) - 0.4%
SNF-inpatient or home health visits (Part B only) (22) 0.6% $7,475,792 0.1% - 1.0%
Hospital-inpatient (including Part A) (11) 0.1% $5,348,576 ( 0.1%) - 0.4%
Clinic-ORF only (eff 4/97); ORF and CMHC (10/91 - 3/97) (74) 0.6% $3,580,835 0.0% - 1.2%
Special facility or ASC surgery-hospice (hospital based) (82) 0.3% $3,139,764 ( 0.3%) - 0.8%
Clinic-CORF (75) 0.6% $1,036,617 ( 0.1%) - 1.4%
Hospital-inpatient or home health visits (Part B only) (12) 0.2% $886,190 ( 0.1%) - 0.5%
Hospital-other (Part B) (14) 0.1% $527,130 ( 0.0%) - 0.2%
Special facility or ASC surgery-ambulatory surgical center (Discontinued for Hospitals Subject to Outpatient PPS; hospitals must use 13X for ASC claims submitted for OPPS payment -- eff. 7/00) (83) 0.0% $95,068 ( 0.0%) - 0.1%
SNF-outpatient (HHA-A also) (23) 0.0% $22,291 ( 0.0%) - 0.0%
Overall 0.5% $452,682,619 0.3% - 0.7%


APPENDIX F: OVERPAYMENTS

Tables F1 through F4 provide for each contractor type (Carrier/DMERC/FI) the service-specific overpayment rates. Each table contains information for the top 20 improperly paid services. FY 2004 was the first year that CMS included service specific overpayment rates. The tables are sorted in descending order by projected improper payments.

F1a: Service Specific Overpayment Rates: Part B

Sort This Table
Service Billed to Carrier (HCPCS) Number of Claims in Sample Number of Lines in Sample Dollars Overpaid in Sample Total Dollars Paid in Sample Projected Dollars Overpaid Overpayment Rate
All Codes With Less Than 30 Claims 8,339 12,085 $44,348 $1,689,441 $717,976,820 3.5%
Office/outpatient visit, est (99214) 4,263 4,287 $20,271 $318,375 $265,381,476 6.6%
Subsequent hospital care (99233) 683 1,055 $18,005 $88,484 $248,432,785 19.5%
Subsequent hospital care (99232) 1,795 3,073 $14,646 $184,509 $221,457,536 8.5%
Initial hospital care (99223) 418 420 $9,725 $56,216 $127,403,441 17.1%
Office/outpatient visit, est (99215) 539 541 $10,498 $55,757 $122,596,898 17.4%
Office consultation (99244) 364 364 $9,646 $55,946 $121,501,648 17.5%
Inpatient consultation (99254) 404 405 $8,825 $51,756 $120,074,929 16.3%
Inpatient consultation (99255) 194 194 $8,714 $32,353 $119,746,762 24.7%
Office consultation (99245) 159 159 $7,201 $29,797 $85,300,335 19.7%
Office/outpatient visit, est (99213) 7,453 7,496 $6,579 $353,310 $79,679,203 1.9%
Office/outpatient visit, new (99204) 245 245 $5,107 $26,902 $71,554,129 21.5%
Critical care, first hour (99291) 168 265 $3,917 $51,979 $53,993,658 7.5%
Nursing fac care, subseq (99309) 293 317 $2,977 $21,450 $47,000,660 16.0%
Office/outpatient visit, new (99203) 433 433 $3,654 $34,587 $45,183,707 10.1%
Therapeutic exercises (97110) 1,108 1,371 $4,169 $54,118 $44,310,701 7.0%
Emergency dept visit (99285) 476 476 $3,625 $65,783 $42,989,796 5.2%
Office consultation (99243) 354 354 $3,643 $38,338 $42,439,964 9.1%
Subsequent hospital care (99231) 704 1,141 $2,831 $39,183 $42,263,237 8.4%
Methylprednisolone 80 MG inj (J1040) 90 91 $1,811 $2,533 $36,732,488 79.0%
All Other Codes 36,756 65,793 $63,507 $2,723,034 $749,532,491 2.2%
Combined 54,135 100,565 $253,701 $5,973,852 $3,405,552,666 4.5%

F2a: Service Specific Overpayment Rates: DME

Sort This Table
Service Billed to DMERC (HCPCS) Number of Claims in Sample Number of Lines in Sample Dollars Overpaid in Sample Total Dollars Paid in Sample Projected Dollars Overpaid Overpayment Rate
All Codes With Less Than 30 Claims 2,058 3,214 $58,792 $487,456 $423,883,712 14.4%
Blood glucose/reagent strips (A4253) 1,781 1,807 $18,961 $176,291 $102,165,245 9.9%
Neg press wound therapy pump (E2402) 30 31 $10,299 $27,892 $86,444,132 45.0%
Levalbuterol non-comp unit (J7614) 132 137 $8,626 $48,914 $71,865,007 20.0%
Budesonide non-comp unit (J7626) 94 104 $7,927 $30,736 $65,110,371 29.9%
EF spec metabolic noninherit (B4154) 55 57 $5,666 $22,254 $44,683,314 28.4%
Powered pres-redu air mattrs (E0277) 51 54 $3,997 $19,836 $33,546,963 24.3%
Enteral feed supp pump per d (B4035) 104 110 $3,267 $26,574 $23,496,464 14.0%
Oxygen concentrator (E1390) 1,685 1,757 $4,788 $307,132 $22,756,362 1.2%
Albuterol ipratrop non-comp (J7620) 284 288 $2,065 $32,120 $15,597,180 7.8%
Cont airway pressure device (E0601) 401 435 $1,519 $33,265 $9,485,540 5.1%
Humidifier heated used w PAP (E0562) 107 115 $1,355 $10,392 $9,334,994 14.8%
Lancets per box (A4259) 1,036 1,039 $1,562 $18,408 $8,012,840 7.3%
Disp fee inhal drugs/30 days (Q0513) 665 677 $990 $20,658 $6,375,668 4.9%
RAD w/o backup non-inv intfc (E0470) 60 62 $1,030 $10,966 $6,283,663 10.9%
High strength ltwt whlchr (K0004) 135 146 $1,102 $10,729 $5,865,048 8.3%
Hosp bed semi-electr w/ matt (E0260) 383 402 $787 $38,601 $4,570,281 1.9%
EF complet w/intact nutrient (B4150) 73 75 $799 $16,054 $4,322,960 4.5%
Nasal application device (A7034) 106 106 $706 $10,142 $4,306,554 7.2%
Lightweight wheelchair (K0003) 173 185 $793 $10,368 $4,124,907 6.6%
All Other Codes 5,039 6,535 $9,967 $257,055 $59,578,005 3.8%
Combined 10,191 17,336 $144,998 $1,615,843 $1,011,809,210 10.2%

F3a: Service Specific Overpayment Rates: Part A

Sort This Table
Service Billed to Fiscal Intermediary (Type of Bill) Number of Claims in Sample Dollars Overpaid in Sample Total Dollars Paid in Sample Projected Dollars Overpaid Overpayment Rate
Hospital-outpatient (HHA-A also)(under OPPS 13X must be used for ASC claims submitted for OPPS payment -- eff. 7/00) (13) 36,629 $168,993 $12,124,768 $349,576,776 1.4%
SNF-inpatient (including Part A) (21) 1,523 $103,025 $7,168,151 $260,120,823 1.2%
HHA-inpatient or home health visits (Part B only) (32) 1,090 $30,177 $2,492,134 $127,082,233 1.5%
Clinic-hospital based or independent renal dialysis facility (72) 1,264 $30,488 $2,845,139 $78,289,612 1.1%
SNF-inpatient or home health visits (Part B only) (22) 899 $21,200 $429,695 $77,995,363 5.7%
Special facility or ASC surgery-rural primary care hospital (eff 10/94) (85) 5,771 $63,020 $1,991,621 $63,085,852 2.5%
Special facility or ASC surgery-hospice (non-hospital based) (81) 879 $15,859 $2,286,149 $54,393,940 0.7%
HHA-outpatient (HHA-A also) (33) 702 $11,441 $1,692,300 $52,057,840 0.9%
Hospital-inpatient or home health visits (Part B only) (12) 153 $8,094 $125,719 $23,740,760 6.3%
Special facility or ASC surgery-hospice (hospital based) (82) 111 $5,041 $318,748 $17,692,360 1.6%
Clinic-ORF only (eff 4/97); ORF and CMHC (10/91 - 3/97) (74) 838 $5,794 $243,031 $13,966,180 2.4%
Clinic-CORF (75) 143 $4,873 $62,015 $13,475,406 8.1%
SNF-outpatient (HHA-A also) (23) 171 $2,761 $56,359 $8,477,377 4.6%
Clinic-independent provider based FQHC (eff 10/91) (73) 572 $786 $52,548 $6,550,678 1.5%
Hospital-inpatient (including Part A) (11) 506 $6,232 $3,377,831 $5,442,542 0.1%
Hospital-other (Part B) (14) 7,302 $2,662 $227,254 $3,822,830 0.8%
Clinic-rural health (71) 3,262 $1,434 $285,357 $3,310,678 0.6%
Clinic-CMHC (eff 4/97) (76) 76 $929 $89,843 $2,448,717 1.2%
Special facility or ASC surgery-ambulatory surgical center (Discontinued for Hospitals Subject to Outpatient PPS; hospitals must use 13X for ASC claims submitted for OPPS payment -- eff. 7/00) (83) 84 $295 $201,621 $788,627 0.2%
Hospital-swing beds (18) 128 $1,490 $815,107 $574,844 0.1%
All Other Codes 177 $0 $6,262 $0 0.0%
Combined 62,280 $484,593 $36,891,654 $1,162,893,439 1.3%

F4a: Service Specific Overpayment Rates: Carrier/DMERC/FI/MAC

Service Billed to Carriers/DMERCs/FIs Number of Claims in Sample Dollars Overpaid in Sample Total Dollars Paid in Sample Projected Dollars Overpaid Overpayment Rate
All 126,606 $883,291 $44,481,349 $5,580,255,315 3.2%


APPENDIX G: UNDERPAYMENTS

The tables in this section of the appendix provide underpayment information. Tables G1 through G4 provide for each contractor type (Carrier/DMERC/FI) the service-specific underpayment rates. Data in these tables is sorted by projected dollars underpaid. All estimates in these tables are based on a minimum of 30 claims in the sample with at least one claim underpaid.

G1a: Service Specific Underpayment Rates: Part B

Sort This Table
Service Billed to Carriers (HCPCS) Number of Claims in Sample Number of Lines in Sample Dollars Underpaid in Sample Total Dollars Paid in Sample Projected Dollars Underpaid Underpymt Rate
Office/outpatient visit, est (99213) 7,453 7,496 $2,365 $353,310 $29,172,251 0.7%
Office/outpatient visit, est (99212) 1,626 1,634 $1,839 $53,766 $21,632,672 3.4%
All Codes With Less Than 30 Claims 8,339 12,085 $1,456 $1,689,441 $16,368,913 0.1%
Darbepoetin alfa, non-esrd (J0881) 96 104 $907 $60,696 $11,721,979 1.3%
Subsequent hospital care (99231) 704 1,141 $970 $39,183 $10,644,187 2.1%
Subsequent hospital care (99232) 1,795 3,073 $870 $184,509 $9,894,343 0.4%
Office/outpatient visit, est (99211) 693 711 $551 $12,240 $4,649,056 3.0%
Emergency dept visit (99283) 341 341 $325 $18,192 $4,405,509 2.1%
Chiropractic manipulation (98940) 377 563 $417 $10,950 $4,300,134 3.3%
Ground mileage (A0425) 945 1,055 $536 $58,034 $3,884,281 0.7%
Epoetin alfa, non-esrd (J0885) 108 111 $201 $35,076 $2,702,757 0.7%
Nursing fac care, subseq (99307) 271 298 $233 $9,016 $2,687,956 2.7%
ESRD related svs 2-3 mo 20+y (G0318) 38 38 $56 $8,372 $2,092,034 1.9%
Office consultation (99244) 364 364 $172 $55,946 $2,077,677 0.3%
Eye exam established pat (92012) 495 504 $133 $29,092 $1,793,781 0.5%
Drain/inject, joint/bursa (20610) 333 372 $144 $21,599 $1,658,182 0.6%
Office consultation (99241) 34 34 $178 $1,398 $1,355,973 9.7%
Destruct premalg les, 2-14 (17003) 244 249 $162 $9,195 $1,343,761 1.2%
Office/outpatient visit, est (99214) 4,263 4,287 $94 $318,375 $1,259,498 0.0%
Office consultation (99243) 354 354 $157 $38,338 $1,140,352 0.2%
All Other Codes 36,888 65,751 $2,296 $2,967,123 $18,014,093 0.0%
Combined 54,135 100,565 $14,061 $5,973,852 $152,799,391 0.2%

G2a: Service Specific Underpayment Rates: DMERCs/DME MACs

Sort This Table
Service Billed to DMERCs Number of Claims in Sample Number of Lines in Sample Dollars Underpaid in Sample Total Dollars Paid in Sample Projected Dollars Underpaid Underpymt Rate
Mycophenolate mofetil oral (J7517) 42 42 $601 $17,538 $1,951,189 1.8%
All Codes With Less Than 30 Claims 2,058 3,214 $229 $487,456 $741,899 0.0%
Blood glucose/reagent strips (A4253) 1,781 1,807 $74 $176,291 $620,122 0.1%
Cont airway pressure device (E0601) 401 435 $84 $33,265 $272,016 0.1%
Sup fee antiem,antica,immuno (Q0511) 91 92 $24 $1,824 $77,923 0.7%
Albuterol non-comp unit (J7613) 329 337 $19 $5,704 $60,586 0.2%
Px sup fee anti-can sub pres (Q0512) 82 92 $16 $1,424 $51,949 0.6%
Ipratropium bromide non-comp (J7644) 217 226 $6 $2,061 $47,592 0.4%
All Other Codes 7,437 11,091 $0 $890,280 $0 0.0%
Combined 10,191 17,336 $1,053 $1,615,843 $3,823,276 0.0%

G3a: Service Specific Underpayment Rates: Part A

Sort This Table
Service Billed to FIs (HCPCS) Number of Claims in Sample Dollars Underpaid in Sample Total Dollars Paid in Sample Projected Dollars Underpaid Underpymt Rate
Hospital-outpatient (HHA-A also)(under OPPS 13X must be used for ASC claims submitted for OPPS payment -- eff. 7/00) (13) 36,629 $43,192 $12,124,768 $78,098,211 0.30%
Special facility or ASC surgery-hospice (non-hospital based) (81) 879 $5,287 $2,286,149 $18,336,592 0.20%
SNF-inpatient (including Part A) (21) 1,523 $7,488 $7,168,151 $15,247,258 0.10%
HHA-inpatient or home health visits (Part B only) (32) 1,090 $4,079 $2,492,134 $12,800,989 0.10%
HHA-outpatient (HHA-A also) (33) 702 $3,688 $1,692,300 $11,701,399 0.20%
Clinic-hospital based or independent renal dialysis facility (72) 1,264 $5,033 $2,845,139 $4,475,321 0.10%
Special facility or ASC surgery-rural primary care hospital (eff 10/94) (85) 5,771 $2,677 $1,991,621 $3,508,209 0.10%
SNF-inpatient or home health visits (Part B only) (22) 899 $411 $429,695 $1,025,012 0.10%
Hospital-inpatient (including Part A) (11) 506 $1,341 $3,377,831 $751,070 0.00%
Clinic-ORF only (eff 4/97); ORF and CMHC (10/91 - 3/97) (74) 838 $210 $243,031 $578,581 0.10%
Clinic-CORF (75) 143 $28 $62,015 $193,832 0.10%
SNF-outpatient (HHA-A also) (23) 171 $25 $56,359 $183,828 0.10%
Hospital-other (Part B) (14) 7,302 $57 $227,254 $69,382 0.00%
All Other Codes 4,563 $0 $1,895,206 $0 0.00%
Combined 62,280 $73,518 $36,891,654 $146,969,684 0.20%

G4a: Service Specific Underpayment Rates: Carrier/DMERC/FI/MAC

Service Billed to Carriers/DMERCs/FIs Number of Claims in Sample Number of Lines in Sample Dollars Underpaid in Sample Total Dollars Paid in Sample Projected Dollars Underpaid Underpymt Rate
All 17,917 22,819 $19,058 $7,282,176 $48,827,913 0.1%


APPENDIX H: STATISTICS AND OTHER INFORMATION FOR THE CERT SAMPLE

The tables in this section of the appendix provide statistics and other information that can be calculated from the CERT sample data. Table H1 provides information on the sample size for each cluster included in the report. This table provides data by claim. It is not comparable to other tables that are by line item for Part B and DME and by claim for Part A.

H1a: Carrier Size of Universe and Size of Review Sample

Sort This Table
Cluster Number of Claims Reviewed Number of Claims Containing Errors Percent of Claims Containing Errors
All 54,135 4,672 8.6%
First Coast Service Options FL 00590 2,775 295 10.6%
First Coast Service Options CT 00591 1,948 150 7.7%
Palmetto SC 00880 2,002 165 8.2%
WPS WI/IL/MI/MN 00951/00952/00953/00954 1,940 163 8.4%
Trailblazer TX 00900 1,944 170 8.7%
Cahaba AL/GA/MS 00510/00511/00512 1,952 175 9.0%
NHIC CA 31140/31146 1,995 214 10.7%
Trailblazer MD/DE/DC/VA 00901/00902/00903/00904 1,986 182 9.2%
NHIC ME/MA/NH/VT 31142/31143/31144/31145 1,956 134 6.9%
Noridian ND/CO/WY/IA/SD 00820/00824/00825/00826/00889 1,810 125 6.9%
Palmetto OH/WV 00883/00884 1,912 151 7.9%
HGSA PA 00865 1,974 114 5.8%
HealthNow NY 00801 1,925 151 7.8%
GHI NY 14330 1,840 166 9.0%
BCBS MT 00751 1,268 74 5.8%
Noridian UT 00823 1,280 114 8.9%
Noridian AK/AZ/HI/NV/OR/WA 00831/00832/00833/00834/00835/00836 2,036 159 7.8%
AdminaStar IN/KY 00630/00660 1,933 123 6.4%
BCBS KS/NE/W MO 00650/00655/00651 2,016 147 7.3%
Triple S, Inc. PR/VI 00973/00974 2,028 356 17.6%
Empire NY 00803 1,983 246 12.4%
Empire NJ 00805 1,970 223 11.3%
CIGNA ID 05130 1,962 111 5.7%
CIGNA TN 05440 2,004 149 7.4%
CIGNA NC 05535 1,991 156 7.8%
BCBS AR AR/NM/OK/MO/LA 00520/00521/00522/00523/00528 2,041 164 8.0%
BCBS AR RI 00524 1,986 150 7.6%
Noridian MAC Region 3 03002 1,678 145 8.6%

H1b: DMERC Size of Universe and Size of Review Sample

Sort This Table
Cluster Number of Claims Reviewed Number of Claims Containing Errors Percent of Claims Containing Errors
All 10,191 656 6.4%
AdminaStar Region B 00635 944 54 5.7%
Palmetto Region C 00885 2,889 203 7.0%
CIGNA Region D 05655 1,046 41 3.9%
Tricenturion Region A 77011 492 23 4.7%
NHIC MAC Region A 16003 1,279 87 6.8%
National Government Services MAC Region B 17003 2,483 174 7.0%
Noridian Administrative Services MAC Region D 19003 1,058 74 7.0%

H1c: FI Size of Universe and Size of Review Sample

Sort This Table
Cluster Number of Claims Reviewed Number of Claims Containing Errors Percent of Claims Containing Errors
All 62,280 2,775 4.5%
Cahaba AL 00010 1,865 78 4.2%
BCBS GA GA 00101 1,973 104 5.3%
First Coast Service Options FL 00090 2,035 117 5.7%
BCBS AR AR 00020 1,973 110 5.6%
Cahaba IA/SD 00011 1,973 43 2.2%
AdminaStar IN/IL/KY/OH 00130/00131/00160/00332 1,978 89 4.5%
BCBS KS KS 00150 1,920 66 3.4%
Anthem ME/MA 00180/00181 2,115 78 3.7%
Anthem NH/VT 00270 2,068 80 3.9%
Highmark Medicare Services DC/MD 00366 1,929 131 6.8%
Trispan LA/MO/MS 00230 2,093 103 4.9%
Palmetto NC 00382 2,068 81 3.9%
Noridian MN/ND 00320/00321 1,727 50 2.9%
Mutual of Omaha (all states) 52280 2,359 130 5.5%
Empire CT/DE/NY 00308 2,062 102 4.9%
Chisholm OK 00340 1,965 74 3.8%
Veritus PA 00363 1,883 59 3.1%
COSVI PR/VI 57400 2,009 223 11.1%
Palmetto SC 00380 2,149 57 2.7%
Riverbend NJ/TN 00390 1,982 67 3.4%
Trailblazer CO/NM/TX 00400 1,900 108 5.7%
BCBS AZ AZ 00030 835 35 4.2%
UGS VA/WV 00453 1,979 82 4.1%
UGS AS/CA/GU/HI/NV/NMI 00454 1,963 108 5.5%
UGS WI/MI 00450/00452 1,955 53 2.7%
BCBS WY WY 00460 1,140 71 6.2%
BCBS MT MT 00250 1,293 37 2.9%
Noridian AK/WA 00322 2,056 65 3.2%
Noridian ID/OR/UT 00323/00325 1,781 88 4.9%
BCBS NE NE 00260 2,006 50 2.5%
BCBS AR RI 00021 1,992 77 3.9%
Noridian MAC Region 3 03001 3,254 159 4.9%

Table H2 series provides information on the sample size for each category for which this report makes national estimates. These tables also show the number of claims containing errors and the percent of claims with payment errors. Data in these tables for Partrt B and DME data is expressed in terms of line items, and data in these tables for Part A data is expressed in terms of claims. Totals cannot be calculated for these categories since CMS is using different units for each type of service.

H2a: Claims in Error: Part B

Sort This Table
Variable Number of Claims Reviewed Number of Claims Containing Errors Percent of Claims Containing Errors
Hcpcs Procedure Code
All Codes With Less Than 30 Claims 12,085 454 3.8%
Complete cbc w/auto diff wbc (85025) 1,971 23 1.2%
Comprehen metabolic panel (80053) 1,464 13 0.9%
Office/outpatient visit, est (99212) 1,634 126 7.7%
Office/outpatient visit, est (99213) 7,496 340 4.5%
Office/outpatient visit, est (99214) 4,287 602 14.0%
Prothrombin time (85610) 1,482 12 0.8%
Routine venipuncture (36415) 4,468 82 1.8%
Subsequent hospital care (99232) 3,073 353 11.5%
Therapeutic exercises (97110) 1,371 112 8.2%
Other 61,234 3,797 6.2%
TOS Code
Hospital visit - subsequent 5,943 947 15.9%
Lab tests - automated general profiles 2,392 18 0.8%
Lab tests - blood counts 2,427 37 1.5%
Lab tests - other (non-Medicare fee schedule) 11,741 153 1.3%
Lab tests - routine venipuncture (non Medicare fee schedule) 4,528 82 1.8%
Minor procedures - other (Medicare fee schedule) 6,185 436 7.0%
Office visits - established 14,976 1,420 9.5%
Specialist - opthamology 2,964 49 1.7%
Standard imaging - chest 2,511 45 1.8%
Standard imaging - musculoskeletal 2,405 71 3.0%
Other 44,493 2,656 6.0%
Resolution Type
Automated 20,003 110 0.5%
Complex 71 3 4.2%
None 80,269 5,794 7.2%
Routine 222 7 3.2%
Diagnosis Code
Arthropathies and related disorders 4,999 362 7.2%
Diseases of other endocrine glands 4,640 206 4.4%
Diseases of the blood and bloodforming organs 3,175 180 5.7%
Disorders of the eye and adnexa 4,358 135 3.1%
Dorsopathies 3,919 293 7.5%
Hypertensive disease 5,003 262 5.2%
Other forms of heart disease 5,461 340 6.2%
Other metabolic disorders and immunity disorders 3,858 121 3.1%
Persons encountering health services for specific procedures and aftercare 2,886 65 2.3%
Symptoms 10,750 740 6.9%
Other 51,516 3,210 6.2%

H2b: Claims in Error: DME

Sort This Table
Variable Number of Claims Reviewed Number of Claims Containing Errors Percent of Claims Containing Errors
Hcpcs Procedure Code
All Codes With Less Than 30 Claims 3,214 220 6.8%
Blood glucose/reagent strips (A4253) 1,807 212 11.7%
Calibrator solution/chips (A4256) 465 18 3.9%
Cont airway pressure device (E0601) 435 20 4.6%
Disp fee inhal drugs/30 days (Q0513) 677 32 4.7%
Hosp bed semi-electr w/ matt (E0260) 402 7 1.7%
Lancets per box (A4259) 1,039 86 8.3%
Nebulizer with compression (E0570) 730 26 3.6%
Oxygen concentrator (E1390) 1,757 24 1.4%
Portable gaseous 02 (E0431) 1,160 19 1.6%
Other 5,650 320 5.7%
TOS Code
All Policy Groups with Less than 30 Claims 473 25 5.3%
CPAP 1,120 70 6.3%
Enteral Nutrition 473 37 7.8%
Glucose Monitor 3,696 336 9.1%
Hospital Beds/Accessories 514 9 1.8%
Nebulizers & Related Drugs 3,137 158 5.0%
Ostomy Supplies 394 31 7.9%
Oxygen Supplies/Equipment 3,173 45 1.4%
Wheelchairs Manual 793 54 6.8%
Wheelchairs Options/Accessories 493 35 7.1%
Other 3,070 184 6.0%
Resolution Type
Automated 2,990 23 0.8%
Complex 3 0 0.0%
None 14,171 955 6.7%
Routine 172 6 3.5%
Diagnosis Code
All Codes With Less Than 30 Claims 863 39 4.5%
Arthropathies and related disorders 631 41 6.5%
Cerebrovascular disease 333 18 5.4%
Chronic obstructive pulmonary disease and allied conditions 5,424 197 3.6%
Diseases of other endocrine glands 4,062 348 8.6%
Ill-defined and unknown causes of morbidity and mortality 259 8 3.1%
Other diseases of skin and subcutaneous tissue 238 27 11.3%
Other forms of heart disease 601 14 2.3%
Persons with a condition influencing their health status 1,202 84 7.0%
Symptoms 1,652 105 6.4%
Other 2,071 103 5.0%

H2c: Claims in Error: Part A

Sort This Table
Variable Number of Claims Reviewed Number of Claims Containing Errors Percent of Claims Containing Errors
Type Of Bill
Clinic-ORF only (eff 4/97); ORF and CMHC (10/91 - 3/97) (74) 838 64 7.6%
Clinic-hospital based or independent renal dialysis facility (72) 1,264 102 8.1%
Clinic-rural health (71) 3,262 18 0.6%
HHA-inpatient or home health visits (Part B only) (32) 1,090 30 2.8%
Hospital-other (Part B) (14) 7,302 168 2.3%
Hospital-outpatient (HHA-A also)(under OPPS 13X must be used for ASC claims submitted for OPPS payment -- eff. 7/00) (13) 36,629 1,674 4.6%
SNF-inpatient (including Part A) (21) 1,523 101 6.6%
SNF-inpatient or home health visits (Part B only) (22) 899 145 16.1%
Special facility or ASC surgery-hospice (non-hospital based) (81) 879 17 1.9%
Special facility or ASC surgery-rural primary care hospital (eff 10/94) (85) 5,771 348 6.0%
Other 2,823 108 3.8%
TOS Code
ESRD 1,264 102 8.1%
FQHC 572 9 1.6%
Free Standing Ambulatory Surgery 84 4 4.8%
HHA 1,969 48 2.4%
Hospice 990 20 2.0%
Non-PPS Hospital In-patient 2,648 113 4.3%
OPPS, Laboratory (an FI), Ambulatory (Billing an FI) 41,919 1,762 4.2%
Other FI Service Types 6,979 436 6.2%
RHCs 3,262 18 0.6%
SNF 2,593 263 10.1%
Diagnosis Code
Arthropathies and related disorders 2,286 120 5.2%
Diseases of other endocrine glands 2,745 148 5.4%
Diseases of the blood and bloodforming organs 1,802 88 4.9%
Dorsopathies 2,056 97 4.7%
Hypertensive disease 2,793 84 3.0%
Other forms of heart disease 3,229 105 3.3%
Other metabolic disorders and immunity disorders 2,280 65 2.9%
Persons encountering health services for specific procedures and aftercare 5,072 229 4.5%
Persons without reported diagnosis encountered during examination and investigation of individuals and populations 2,936 80 2.7%
Symptoms 6,899 315 4.6%
Other 30,182 1,444 4.8%

H3a: Table H3: Included and Excluded in the Sample

Error Rate Paid Line Items Unpaid Line Items Denied For Non-Medical Reasons Automated Medical Review Denials No Resolution RTP Late Resolution Inpt, RAPS, Tech Errors
Paid Claim Include Include Include Include Exclude Exclude Exclude Exclude
No Resolution Include Include Include Include Include Exclude Include Exclude
Provider Compliance Include Include Include Include Exclude Exclude Exclude Exclude

H4a: Frequency of Claims that are Included and Excluded From Each Error Rate: Part B

Sort This Table
Error Type Included Dropped Total Percent Included
Paid 54,135 2,136 56,271 96.2%
No Resolution 54,137 2,134 56,271 96.2%
Provider Compliance 54,135 2,136 56,271 96.2%

H4b: Frequency of Claims that are Included and Excluded from Each Error Rate: DME

Sort This Table
Error Type Included Dropped Total Percent Included
Paid 10,191 189 10,380 98.2%
No Resolution 10,205 175 10,380 98.3%
Provider Compliance 10,191 189 10,380 98.2%

H4c: Frequency of Claims that are Included and Excluded From Each Error Rate: Part A

Sort This Table
Error Type Included Dropped Total Percent Included
Paid 62,280 4,402 66,682 93.4%
No Resolution 62,365 4,317 66,682 93.5%
Provider Compliance 62,280 4,402 66,682 93.4%