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CMS Corrects Improper Payment Figures, Statistics

James Carroll, for HealthLeaders Media, June 19, 2012

The correction amounts of each quarter of the program are as follows:

  • October 2009–September 2010: $92.3 million
  • October 2010–December 2010: $94.3 million
  • January 2011–March 2011: $208.9 million
  • March 2011–June 2011: $289.3 million
  • July 2011–September 2011: $353.7 million
  • October 2011–December 2011: $422.7 million
  • January 2012–March 2012: $649.9 million

As in the previous report, medical necessity issues remain the top target of each individual Recovery Auditor, three of which are cardiovascular procedures:

  • Region A: Cardiovascular procedures (Medical necessity)
  • Region B: Cardiovascular procedures (Medical necessity)
  • Region C: Cardiovascular procedures (Medical necessity)
  • Region D: Minor surgery and other treatments billed as inpatient stay (Medical necessity)

Also released by CMS in the past month is a report on appeals statistics for fiscal year 2011. The number of claims with overpayment determinations in 2011 was 903,372, but providers only appeal 56,620 of these claims. Of these appeals, 24,548 or 43.4% were reversed in the provider's favor. Considering the relative success of providers in their appeal efforts, the fact that 846,752 claims did not get appealed comes as a bit of a surprise.

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