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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 ContractorsSort 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 ContractorsSort 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 ContractorsSort 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: QIOsSort 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 00630/00660Sort 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 00520/00521/00522/00523/00528Sort 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 05130Sort 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 05535Sort 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 |
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 05440Sort 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 |
3.0% |
$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 00510/00511/00512Sort 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 |
3.6% |
$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 00590Sort 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 |
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 00591Sort 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 |
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 00650/00655/00651Sort 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 |
2.8% |
$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 00751Sort 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 |
1.6% |
$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 00801Sort 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 |
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 00803Sort 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 |
4.7% |
$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 00805Sort 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 |
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 00820/00824/00825/00826/00889Sort 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 |
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 00831/00832/00833/00834/00835/00836Sort 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 00865Sort 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 |
3.2% |
$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 00524Sort 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 |
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 00880Sort 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 |
2.9% |
$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 00883/00884Sort 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 |
4.0% |
$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 00900Sort 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 |
3.1% |
$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 00901/00902/00903/00904Sort 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 00823Sort 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% |
$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 00973/00974Sort 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 |
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 14330Sort 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 |
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 31140/31146Sort 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 31142/31143/31144/31145Sort 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 00951/00952/00953/00954Sort 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 03102/03202/03302/03502Sort 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 00635Sort 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 77011Sort 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 00885Sort 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 05655Sort 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 16003Sort 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 17003Sort 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 00130/00131/00160/00332Sort 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 00180/00181Sort 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 00270Sort 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 00010Sort 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 00020Sort 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 00030Sort 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 00090Sort 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 00101Sort 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 00011Sort 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 00150Sort 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 00230Sort 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 00250Sort 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 00382Sort 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 00260Sort 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) |
2.2% |
$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 00021Sort 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 00380Sort 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 00460Sort 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 00366Sort 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 57400Sort 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 00308Sort 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 00340Sort 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 00363Sort 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) 52280Sort 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 00320/00321Sort 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 00322Sort 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 00323/00325Sort 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 00390Sort 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 00400Sort 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 00454Sort 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 00450/00452Sort 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 00453Sort 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 DocumentationSort 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 DocumentationSort 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:
- 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.
- 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.
- 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.
- 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.
- Third Party Record - This category contains situations in which the provider indicated that a different provider, a third party, has the relevant medical record.
- 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 ContractorSort 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 ASort 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 reviewedSort 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 BSort 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: DMESort 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 ASort 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 BSort 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: DMESort 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 ASort 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 ASort 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 SampleSort 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 SampleSort 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 SampleSort 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 BSort 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: DMESort 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 ASort 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 BSort 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: DMESort 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 ASort 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% |
|