November 2016 PERM Report Appendix - CMS · November 2016 . Appendix 1: Medicaid Trending for...

November 2016 PERM Report Appendix

November 2016

List of Appendices

Appendix 1: Medicaid Trending for Cycle-Specific and National Rolling Improper Payment Rates ........................................................................................................................... 1

Appendix 2: Medicaid Supplemental Information ......................................................................... 2 Appendix 3: CHIP Trending for Cycle-Specific and National Rolling Improper Payment Rates 26 Appendix 4: CHIP Supplemental Information ............................................................................. 27 Appendix 5: Medicaid and CHIP Review Methodology .............................................................. 50 Appendix 6: Statistical Sampling and Formulae .......................................................................... 54

Note: Appendices 2 and 4 contain their own Supplemental Information Table of Contents.

November 2016

Appendix 1: Medicaid Trending for Cycle-Specific and National Rolling Improper Payment Rates

Table A1. Inception to Date Cycle-Specific Medicaid Component Improper Payment Rates

– 1 – November 2016

Year FFS Managed Care Eligibility Overall**

2007 4.7% 2008 8.9% 3.1% 2.9% 10.5% 2009 2.6% 0.1% 6.7% 8.7% 2010 1.9% 0.1% 7.6% 9.0% 2011 3.6% 0.5% 4.0% 6.7% 2012 3.3% 0.3% 3.3% 5.8% 2013 3.4% 0.2% 3.3% 5.7% 2014 8.8% 0.1% 2.3% 8.2% 2015 18.6% 0.1% N/A* N/A* 2016 9.8% 0.5% N/A* N/A*

*For the 2015 and 2016 measurements, eligibility reviews are suspended. Therefore, eligibility component improper payment rates have been removed for the 2015 and 2016 rates. **The overall estimate is comprised of the weighted sum of the FFS and managed care components, plus the eligibility component, minus a small adjustment to account for the overlap between the claims and eligibility review functions. From 2007-2013, the cycle-specific rate is calculated using data from the 17 states sampled and projected to the national level. From 2014 onward, the cycle-specific rate represents only the 17 states sampled.

Table A2. National Rolling Medicaid Component Improper Payment Rates


2010 Rolling Rates 4.4% 1.0% 5.9% 9.4% 2011 Rolling Rates 2.7% 0.3% 6.0% 8.1% 2012 Rolling Rates 3.0% 0.3% 4.9% 7.1% 2013 Rolling Rates 3.6% 0.3% 3.3% 5.8% 2014 Rolling Rates 5.1% 0.2% 3.1% 6.7% 2015 Rolling Rates 10.6% 0.1% 3.1%* 9.8% 2016 Rolling Rates 12.4% 0.3% 3.1%* 10.5%

*Rolling eligibility component statistics for 2015 and 2016 reflect the latest eligibility results from the most recent cycles prior to the eligibility freeze. **The overall estimate is comprised of the weighted sum of the FFS and managed care components, plus the eligibility component, minus a small adjustment to account for the overlap between the claims and eligibility review functions.

Table A1. Inception to Date Cycle-Specific Medicaid Component Improper Payment Rates ...................... 1 Table A2. National Rolling Medicaid Component Improper Payment Rates 1

Appendix 2: Medicaid Supplemental Information CMS reported a rolling improper payment rate for Medicaid in 2016 based on the 51 states reviewed from 2014-2016. Unless otherwise noted, all tables and figures in Appendix 2 are based on the rolling rate. There was no eligibility component review from 2015-2016 and eligibility results from the most recent cycles prior to the eligibility freeze are used as a proxy in the overall improper payment rate calculation.

Table S1. Summary of Medicaid Projected Improper Payments .................................................................. 3 Table S2. Summary of Projected Medicaid Overpayments .......................................................................... 3 Table S3. Summary of Projected Medicaid Underpayments ........................................................................ 4 Table S4. Medicaid FFS Medical Review and Data Processing Improper Payment Rates by State .............. 4 Table S5. Summary of Medicaid FFS Projected Dollars by Type of Error ...................................................... 6 Table S6. Summary of Medicaid FFS Medical Review Overall Errors............................................................ 7 Table S7. Summary of Medicaid FFS Medical Review Overpayments .......................................................... 8 Table S8. Summary of Medicaid FFS Medical Review Underpayments ........................................................ 9 Table S9. Specific Causes of Incomplete Documentation Error (MR2) ....................................................... 10 Table S10. Specific Causes of No Documentation Error (MR1)................................................................... 11 Table S11. Specific Causes of Number of Unit(s) Error (MR6) .................................................................... 12 Table S12. Medicaid FFS Medical Review Error by Service Type ................................................................ 12 Table S13. Summary of Medicaid FFS Data Processing Overall Improper Payments ................................. 14 Table S14. Summary of Medicaid FFS Data Processing Overpayments ...................................................... 14 Table S15. Summary of Medicaid FFS Data Processing Underpayments ................................................... 15 Table S16. Specific Causes of Provider Information/Enrollment Error (DP10) ........................................... 16 Table S17. Specific Sub-Causes of Provider Information/Enrollment Error (DP10) .................................... 17 Table S18. Specific Causes of Non-covered Service/Recipient Error (DP2) ................................................ 18 Table S19. Specific Causes of Data Entry Error (DP7) ................................................................................. 18 Table S20. Medicaid FFS Data Processing Error by Service Type ................................................................ 19 Table S21. Medicaid Managed Care Data Processing Improper Payment Rates by State.......................... 21 Table S22. Summary of Medicaid Managed Care Data Processing Projected Dollars by Type of Error ..... 22 Table S23. Summary of Medicaid Managed Care Data Processing Overpayments .................................... 23 Table S24. Summary of Medicaid Managed Care Data Processing Underpayments ................................. 23 Table S25. Specific Causes of Non-covered Service/Recipient Error (DP2) ................................................ 24 Table S26. Specific Causes of Provider Information/Enrollment Error (DP10) ........................................... 24 Table S27. Specific Causes of Duplicate Claim Error (DP1) ......................................................................... 25


Medicaid Overpayments and Underpayments

Table S1. Summary of Medicaid Projected Improper Payments


Category

Number of

Sample Improper Payments

Number of

Claims Sampled


Sample Paid Amount

Projected Improper Payments (millions)

Projected Paid

Amount (millions)

Improper Payment

Rate 95% CI

FFS 3,508 23,682 $9,021,559.5 $590,002,508.5 $43,844.6 $353,152.8 12.4% 11.2% - 13.6%

FFS Medical Review 663 23,682 $574,822.3 $590,002,508.5 $6,813.2 $353,152.8 1.9% 1.5% - 2.3%

FFS Data Processing 3,011 23,682 $8,564,510.7 $590,002,508.5 $39,112.0 $353,152.8 11.1% 9.9% - 12.2%

Managed Care 25 9,691 $35,771.3 $10,271,730.0 $581.4 $230,784.2 0.3% 0.1% - 0.4%

Eligibility 1,054 25,914 $419,948.2 $13,922,896.8 $18,142.8 $583,937.1 3.1% 2.2% - 4.0%

Total 4,587 59,287 $9,477,279.0 $614,197,135.4 $61,188.5 $583,937.1 10.5% 9.4% - 11.6%

Note: Details do not always sum to the total due to rounding. Eligibility component statistics reflect the most recent eligibility calculations prior to 2016.

Table S2. Summary of Projected Medicaid Overpayments

Category

Number of


Number of

Claims Sampled


Sample Paid Amount


Projected Paid

Amount (millions)

Improper Payment

Rate 95% CI

FFS 3,479 23,682 $9,014,893.7 $590,002,508.5 $43,423.7 $353,152.8 12.3% 11.1% - 13.5%

FFS Medical Review 663 23,682 $574,822.3 $590,002,508.5 $6,813.2 $353,152.8 1.9% 1.5% - 2.3%

FFS Data Processing 2,980 23,682 $8,557,841.0 $590,002,508.5 $38,690.9 $353,152.8 11.0% 9.8% - 12.1%

Managed Care 25 9,691 $35,771.3 $10,271,730.0 $581.4 $230,784.2 0.3% 0.1% - 0.4%

Eligibility 1,009 25,914 $414,366.4 $13,922,896.8 $17,666.5 $583,937.1 3.0% 2.1% - 4.0%

Total 4,513 59,287 $9,465,031.4 $614,197,135.4 $60,340.3 $583,937.1 10.3% 9.2% - 11.4%


Table S3. Summary of Projected Medicaid Underpayments


Category

Number of


Number of

Claims Sampled


Sample Paid Amount


Projected Paid

Amount (millions)

Improper Payment

Rate 95% CI

FFS 31 23,682 $6,669.7 $590,002,508.5 $421.1 $353,152.8 0.1% ( 0.1%) - 0.3%

FFS Medical Review 0 23,682 $0.0 $590,002,508.5 $0.0 $353,152.8 0.0% 0.0% - 0.0%

FFS Data Processing 31 23,682 $6,669.7 $590,002,508.5 $421.1 $353,152.8 0.1% ( 0.1%) - 0.3%

Managed Care 0 9,691 $0.0 $10,271,730.0 $0.0 $230,784.2 0.0% 0.0% - 0.0%

Eligibility 45 25,914 $5,581.7 $13,922,896.8 $476.3 $583,937.1 0.1% 0.0% - 0.2%

Total 76 59,287 $12,251.5 $614,197,135.4 $897.0 $583,937.1 0.2% ( 0.0%) - 0.3% Note: Details do not always sum to the total due to rounding. Eligibility component statistics reflect the most recent eligibility calculations prior to 2016.

Medicaid FFS Component Improper Payment Rate

Table S4. Medicaid FFS Medical Review and Data Processing Improper Payment Rates by State

State

Medical Review Data Processing

Sample Paid Amount

FFS Improper Payment

Rate

Number of



Improper Payment

Rate

Number of



Improper Payment

Rate

National 663 $574,822.3 1.9% 3,011 $8,564,510.7 11.1% $590,002,508.5 12.4%

Cycle 3 - ST1 10 $6,044.0 1.4% 124 $378,787.9 45.5% $951,586.6 46.2%

Cycle 3 - ST2 67 $33,147.8 7.7% 237 $967,732.2 23.7% $4,346,355.2 29.8%

Cycle 3 - ST3 1 $0.0 0.0% 91 $280,904.2 29.6% $1,059,969.5 29.6%

Cycle 1 - ST4 48 $36,248.9 3.6% 229 $532,441.4 26.6% $1,550,735.7 28.6%

Cycle 1 - ST5 7 $4,308.4 0.2% 232 $1,467,259.5 23.7% $2,648,792.9 23.9%

Cycle 1 - ST6 43 $30,368.4 2.6% 202 $342,052.8 17.4% $869,138.7 18.7%

Cycle 3 - ST7 25 $9,142.4 2.4% 136 $579,180.2 16.9% $3,512,204.6 18.6%

Cycle 2 - ST8 2 $60.6 0.1% 17 $14,548.7 17.9% $491,820.7 18.0%

Cycle 2 - ST9 13 $936.0 2.6% 33 $99,407.4 15.2% $469,941.7 17.8%

Cycle 3 - ST10 14 $8,438.2 2.4% 82 $137,875.1 15.5% $3,794,220.4 17.8%


State


Sample Paid Amount


Rate

Number of



Improper Payment

Rate

Number of



Improper Payment

Rate

Cycle 3 - ST11 33 $7,164.3 9.9% 51 $23,303.5 7.4% $1,278,841.2 16.8%

Cycle 1 - ST12 12 $13,956.3 1.9% 74 $333,235.9 14.9% $1,047,128.0 16.6%

Cycle 2 - ST13 8 $634.8 0.9% 24 $137,135.4 15.4% $788,520.6 16.3%

Cycle 1 - ST14 6 $811.9 0.2% 149 $557,636.6 16.1% $3,033,672.6 16.2%

Cycle 3 - ST15 17 $18,882.6 0.9% 151 $654,280.9 15.4% $5,010,203.2 16.0%

Cycle 2 - ST16 10 $2,941.7 6.7% 22 $12,909.4 8.6% $155,472.9 15.3%

Cycle 2 - ST17 6 $4,345.9 1.8% 60 $29,693.1 12.7% $245,411.4 14.3%

Cycle 3 - ST18 27 $57,070.6 8.3% 21 $32,243.6 8.3% $885,260.6 13.8%

Cycle 1 - ST19 64 $176,658.2 9.6% 52 $85,322.4 3.7% $2,573,304.9 12.7%

Cycle 3 - ST20 7 $6,562.0 3.0% 35 $175,981.4 9.9% $723,419.1 12.6%

Cycle 3 - ST21 3 $126.7 0.1% 55 $86,606.0 12.2% $566,547.6 12.4%

Cycle 3 - ST22 9 $3,408.9 2.3% 24 $152,333.2 9.6% $1,057,266.8 11.9%

Cycle 2 - ST23 3 $23.9 0.1% 19 $30,421.4 11.7% $198,955.9 11.8%

Cycle 2 - ST24 7 $2,046.9 11.0% 60 $947.2 0.8% $172,272.3 11.8%

Cycle 3 - ST25 8 $2,927.2 0.4% 39 $78,853.4 11.2% $432,207,201.3 11.3%

Cycle 2 - ST26 9 $923.1 1.5% 38 $14,661.0 10.6% $391,570.6 11.1%

Cycle 2 - ST27 15 $292.5 1.4% 18 $36,154.4 9.7% $207,175.8 11.1%

Cycle 1 - ST28 5 $3,371.1 0.6% 38 $41,502.5 10.2% $1,068,766.3 10.8%

Cycle 3 - ST29 6 $673.7 1.5% 35 $130,813.8 9.8% $1,404,177.8 10.5%

Cycle 2 - ST30 10 $679.9 1.8% 53 $142,225.7 8.7% $905,762.2 10.5%

Cycle 3 - ST31 15 $22,348.7 3.8% 31 $63,886.4 7.2% $885,573.3 10.4%

Cycle 1 - ST32 63 $45,984.5 6.9% 88 $39,984.8 7.8% $100,652,945.7 10.4%

Cycle 3 - ST33 5 $7,835.8 1.2% 32 $285,387.5 8.6% $1,158,002.9 9.9%

Cycle 3 - ST34 4 $14,986.9 3.8% 23 $97,066.0 6.1% $1,009,438.6 8.8%

Cycle 1 - ST35 5 $8,151.8 0.9% 19 $40,786.4 6.7% $1,359,402.2 7.5%

Cycle 1 - ST36 1 $350.0 0.3% 41 $50,827.1 6.8% $460,324.1 7.2%

Cycle 1 - ST37 9 $15,273.1 3.0% 29 $39,956.2 4.3% $1,768,070.4 6.9%

Cycle 1 - ST38 2 $345.8 0.2% 28 $49,288.8 6.5% $611,722.7 6.8%

Cycle 2 - ST39 2 $18.8 0.0% 17 $18,666.2 6.3% $218,090.1 6.3%


State


Sample Paid Amount


Rate

Number of



Improper Payment

Rate

Number of



Improper Payment

Rate

Cycle 1 - ST40 18 $17,082.1 2.2% 74 $90,453.4 4.0% $1,369,638.8 6.1%

Cycle 3 - ST41 4 $66.4 0.2% 23 $74,978.0 5.6% $895,989.0 5.8%

Cycle 2 - ST42 2 $252.6 1.5% 12 $8,965.0 4.3% $238,659.5 5.8%

Cycle 1 - ST43 4 $4,519.9 0.8% 43 $58,707.9 4.9% $1,232,811.5 5.7%

Cycle 2 - ST44 6 $1,067.7 0.8% 15 $5,567.8 4.8% $276,904.8 5.6%

Cycle 1 - ST45 2 $1,914.9 0.3% 36 $35,088.0 4.7% $524,385.4 5.0%

Cycle 1 - ST46 5 $338.9 1.1% 27 $7,601.1 3.7% $708,901.0 4.6%

Cycle 2 - ST47 13 $1,909.9 2.2% 36 $37,278.0 2.6% $1,274,463.9 4.5%

Cycle 2 - ST48 3 $54.3 0.3% 19 $3,240.4 2.4% $192,491.3 2.7%

Cycle 2 - ST49 3 $101.8 1.1% 3 $39.9 0.1% $350,341.8 1.2%

Cycle 1 - ST50 1 $4.0 0.0% 6 $71.3 0.6% $923,281.3 0.6%

Cycle 2 - ST51 1 $17.6 0.0% 8 $221.0 0.2% $275,373.1 0.2%

Medicaid FFS Payment Errors by Type of Error

Table S5. Summary of Medicaid FFS Projected Dollars by Type of Error

Error Type

Number of



Sample Paid Amount


Lower Confidence

Limit (millions)

Upper Confidence

Limit (millions)

Provider Information/Enrollment Error (DP10) 2,405 $8,228,268.1 $8,228,281.3 $35,688.1 $31,483.6 $39,892.6

Incomplete Documentation (MR2) 343 $427,547.9 $427,547.9 $3,630.6 $2,770.2 $4,491.1

No Documentation (MR1) 227 $113,540.6 $113,574.5 $1,748.9 $1,264.6 $2,233.3

Number of Unit(s) Error (MR6) 27 $12,178.3 $21,399.0 $592.8 -$253.8 $1,439.3

Non-covered Service/Recipient (DP2) 112 $153,282.3 $153,282.3 $560.8 $373.6 $748.0

Data Entry Error (DP7) 7 $3,167.9 $10,504.9 $408.4 -$388.1 $1,204.9

Third-party Liability Error (DP4) 9 $9,225.3 $10,355.4 $268.0 -$23.6 $559.6

Inadequate Documentation (MR9) 15 $11,903.6 $11,903.6 $233.9 $29.7 $438.1

Procedure Coding Error (MR3) 8 $1,508.0 $3,063.5 $214.9 -$110.5 $540.3


Error Type

Number of



Sample Paid Amount


Lower Confidence

Limit (millions)

Upper Confidence

Limit (millions)

Administrative/Other (MR10) 4 $1,637.7 $1,637.7 $213.6 -$113.6 $540.7

Pricing Error (DP5) 78 $31,187.9 $245,025.2 $100.8 $45.1 $156.5

Administrative/Other (DP12) 10 $2,740.3 $2,740.3 $84.2 -$15.9 $184.4

Duplicate Claim (DP1) 2 $9,868.0 $9,868.0 $54.7 -$52.4 $161.8

Policy Violation (MR8) 5 $7,346.1 $7,346.1 $15.9 -$7.5 $39.3 FFS Payment for Managed Care Service (DP3) 2 $5,117.6 $5,117.6 $14.1 -$10.0 $38.3

System Logic Edit Error (DP6) 2 $83.0 $80.8 $6.6 -$4.8 $18.0

Claim Filed Untimely (DP11) 1 $2,928.6 $2,928.6 $4.1 N/A N/A

Unbundling (MR5) 4 $13.5 $13.5 $3.8 -$0.7 $8.2

Medically Unnecessary (MR7) 1 $15.0 $111.3 $0.4 N/A N/A Data Processing Technical Deficiency (DTD) 225 $0.0 $371,540.6 $0.0 $0.0 $0.0

Medical Technical Deficiency (MTD) 21 $0.0 $35,418.9 $0.0 $0.0 $0.0

Total 3,508 $9,021,559.5 $590,002,508.5 $43,844.6 $39,361.6 $48,327.6 Note: Details do not always sum to the total due to rounding. This table assumes one error per claim, which means that claims that have DP and MR errors simultaneously are accounted for once. The purpose of this table is to show the total error found per claim and will not necessarily match other tables in this report that only report one type of review error. Additionally, for error types with fewer than two claims per sample stratum, a confidence interval is not calculated.

Medicaid FFS Medical Review Payment Errors

Table S6. Summary of Medicaid FFS Medical Review Overall Errors

Error Type

Number of



Sample Paid Amount


Lower Confidence

Limit (millions)

Upper Confidence

Limit (millions)


No Documentation (MR1) 227 $113,540.6 $113,574.5 $1,748.9 $1,264.6 $2,233.3 Number of Unit(s) Error (MR6) 27 $10,980.2 $21,399.0 $569.4 -$276.4 $1,415.3




Error Type

Number of



Sample Paid Amount


Lower Confidence

Limit (millions)

Upper Confidence

Limit (millions)


Policy Violation (MR8) 5 $7,346.1 $7,346.1 $15.9 -$7.5 $39.3

Unbundling (MR5) 4 $13.5 $13.5 $3.8 -$0.7 $8.2 Medically Unnecessary (MR7) 1 $15.0 $111.3 $0.4 N/A N/A


Total 663 $574,822.3 $590,002,508.5 $6,813.2 $5,379.0 $8,247.4 Note: Details do not always sum to the total due to rounding. Additionally, for error types with fewer than two claims per sample stratum, a confidence interval is not calculated.

Table S7. Summary of Medicaid FFS Medical Review Overpayments

Error Type

Number of



Sample Paid Amount


Lower Confidence

Limit (millions)

Upper Confidence

Limit (millions)


No Documentation (MR1) 227 $113,540.6 $113,574.5 $1,748.9 $1,264.6 $2,233.3 Number of Unit(s) Error (MR6) 27 $10,980.2 $21,399.0 $569.4 -$276.4 $1,415.3





Unbundling (MR5) 4 $13.5 $13.5 $3.8 -$0.7 $8.2 Medically Unnecessary (MR7) 1 $15.0 $111.3 $0.4 N/A N/A


Total 663 $574,822.3 $590,002,508.5 $6,813.2 $5,379.0 $8,247.4 Note: Details do not always sum to the total due to rounding. Additionally, for error types with fewer than two claims per sample stratum, a confidence interval is not calculated.

Table S8. Summary of Medicaid FFS Medical Review Underpayments


Error Type

Number of



Sample Paid Amount


Lower Confidence

Limit (millions)

Upper Confidence

Limit (millions)

No Documentation (MR1) 0 $0.0 $113,574.5 $0.0 N/A N/A Incomplete Documentation (MR2) 0 $0.0 $427,547.9 $0.0 N/A N/A

Procedure Coding Error (MR3) 0 $0.0 $3,063.5 $0.0 N/A N/A

Unbundling (MR5) 0 $0.0 $13.5 $0.0 N/A N/A Number of Unit(s) Error (MR6) 0 $0.0 $21,399.0 $0.0 N/A N/A

Medically Unnecessary (MR7) 0 $0.0 $111.3 $0.0 N/A N/A

Policy Violation (MR8) 0 $0.0 $7,346.1 $0.0 N/A N/A Inadequate Documentation (MR9) 0 $0.0 $11,903.6 $0.0 N/A N/A

Administrative/Other (MR10) 0 $0.0 $1,967.3 $0.0 N/A N/A

Medical Technical Deficiency (MTD) 0 $0.0 $39,965.3 $0.0 N/A N/A

Total 0 $0.0 $590,002,508.5 $0.0 N/A N/A Note: Details do not always sum to the total due to rounding. Additionally, for error types with fewer than two claims per sample stratum, a confidence interval is not calculated.

Medical Review Payment Errors: Incomplete Documentation Error (MR2)

Table S9. Specific Causes of Incomplete Documentation Error (MR2)


Cause of Error

Number of Sample

Improper Payments



Lower Confidence

Limit (millions)

Upper Confidence

Limit (millions)

Provider did not submit a record with daily documentation of specific tasks performed on the sampled DOS 45 $18,502.1 $744.5 $145.4 $1,343.7

Provider did not submit the service plan 47 $68,256.6 $595.2 $279.4 $911.0 Provider did not submit required progress notes applicable to the sampled DOS 48 $75,530.1 $503.5 $256.1 $750.9

Provider did not submit the pharmacy signature log and/or documentation of patient counseling 80 $45,546.3 $456.5 $270.3 $642.7

Individual plan (ISP, ISFP, IEP, or POC,) was present, but not applicable to the sampled DOS 35 $19,843.1 $373.4 $134.9 $611.9

Record does not include a physician’s order for the sampled service 18 $14,905.3 $316.3 $92.4 $540.2 Multiple documents are missing from the record that are required to support payment 26 $86,733.1 $279.2 $79.7 $478.6

Provider did not submit sufficient documentation to support the claim 14 $19,232.6 $168.5 $11.4 $325.7 Required record of recipient acceptance or refusal of medication counseling not provided 17 $11,759.2 $154.4 $32.1 $276.7

Documentation of patient counseling not provided 6 $128.9 $25.2 -$0.6 $51.0

Provider did not submit the required signed timesheet 2 $261.0 $5.3 -$3.1 $13.7

Provider did not submit the required attendance log/census 1 $446.4 $4.1 N/A N/A

Required physician certification/ recertification for services not provided 1 $4,128.7 $3.6 N/A N/A Provider did not submit the required physician certification/recertification of services 2 $62,231.4 $1.0 -$0.3 $2.3

Provider did not submit a valid prescription 1 $43.2 $0.0 N/A N/A

Total 343 $427,547.9 $3,630.6 $2,770.2 $4,491.1

Note: Details do not always sum to the total due to rounding. Additionally, for error causes with fewer than two claims per sample stratum, a confidence interval is not calculated.

Medical Review Payment Errors: No Documentation Error (MR1)

Table S10. Specific Causes of No Documentation Error (MR1)


Cause of Error

Number of Sample

Improper Payments



Lower Confidence

Limit (millions)

Upper Confidence

Limit (millions)

Provider did not respond to the request for records 130 $71,705.0 $882.4 $520.4 $1,244.5 Provider responded with a statement that the recipient was not seen on the sampled DOS 27 $22,428.1 $358.3 $133.1 $583.4

Provider is under fraud investigation 26 $4,398.7 $136.4 $14.1 $258.8

State could not locate the provider 8 $2,891.7 $97.9 -$4.4 $200.3

Provider responded with a statement that records cannot be located 8 $1,728.3 $96.9 -$32.2 $226.0 Provider responded with a statement that he or she billed for the wrong recipient 5 $967.6 $67.5 -$7.7 $142.8

Provider responded that he or she did not have the recipient on file or in the system 9 $5,149.3 $48.9 $5.8 $92.0

Provider responded that he or she is no longer operating business/practice, and the record is unavailable 6 $1,924.1 $45.0 -$14.5 $104.5

Other 3 $1,128.2 $8.9 -$6.8 $24.6 Provider responded with a statement that there was no documentation for the encounter/billed service 4 $140.3 $5.6 -$2.1 $13.3

Provider did not submit medical records, only the PERM cover sheet 1 $1,079.4 $1.0 N/A N/A

Total 227 $113,540.6 $1,748.9 $1,264.6 $2,233.3


Medical Review Payment Errors: Number of Unit(s) Error (MR6)

Table S11. Specific Causes of Number of Unit(s) Error (MR6)


Cause of Error

Number of Sample

Improper Payments



Lower Confidence

Limit (millions)

Upper Confidence

Limit (millions)

Number of units billed exceeds number of units authorized 22 $10,025.7 $566.6 -$279.2 $1,412.4

Provider miscalculated the number of units 5 $954.5 $2.9 $0.0 $5.8

Total 27 $10,980.2 $569.4 -$276.4 $1,415.3


Medicaid FFS Medical Review Errors by Service Type

Table S12. Medicaid FFS Medical Review Error by Service Type

Category

Number of


Number of

Claims Sampled


Sample Paid Amount


Projected Paid

Amount (millions)

Improper Payment

Rate 95% CI

Personal Support Services 105 1,169 $34,189.5 $356,370.1 $1,387.6 $26,780.0 5.2% 1.8% - 8.6%

Habilitation and Waiver Programs, School Services 113 3,230 $82,940.0 $4,054,734.2 $1,335.8 $52,199.6 2.6% 1.5% - 3.6%

Prescribed Drugs 138 2,734 $79,059.1 $2,464,847.5 $1,050.9 $34,045.6 3.1% 1.8% - 4.4%

Nursing Facility, Intermediate Care Facilities 60 2,769 $134,925.3 $11,145,536.0 $961.4 $71,090.6 1.4% 0.8% - 1.9%

Inpatient and Outpatient Hospital 29 3,171 $16,421.4 $24,954,982.9 $545.9 $52,573.6 1.0% 0.8% - 1.2%

Physicians and Other Licensed Practitioner Services 36 967 $6,796.6 $195,748.0 $378.7 $11,267.7 3.4% 0.6% - 6.2%

Psychiatric, Mental Health, and Behavioral Health Services 51 1,379 $28,717.0 $3,381,189.4 $248.2 $19,677.1 1.3% 0.5% - 2.0%

Dental and Other Oral Surgery Services 25 681 $4,257.2 $80,303.4 $181.2 $5,839.1 3.1% 1.4% - 4.8%


Category

Number of


Number of

Claims Sampled


Sample Paid Amount


Projected Paid

Amount(millions)

Improper Payment

Rate95% CI

Clinics 11 652 $6,894.9 $251,343.5 $165.4 $9,057.9 1.8% 1.3% - 2.3%

ICF for Individuals with Intellectual Disabilities and Group Homes 13 734 $171,465.9 $7,941,626.6 $152.7 $11,542.1 1.3% 0.7% - 1.9%

Transportation and Accommodations 17 280 $1,256.7 $68,432.7 $124.1 $2,930.4 4.2% ( 3.2%) - 11.6%

Home Health Services 29 382 $4,426.7 $231,607.6 $101.6 $7,021.4 1.4% 0.7% - 2.2%

Durable Medical Equipment (DME) and Supplies, Prosthetic/Orthopedic Devices, and Environmental Modifications

10 273 $2,699.0 $120,626.1 $91.4 $3,440.9 2.7% 0.5% - 4.8%

Occupational, Respiratory Therapies; Speech Language Pathology, Audiology; Ophthalmology, Optometry, and Optical Services & Rehabilitation Services, Necessary Supplies & Equipment

10 222 $406.7 $17,119.6 $52.1 $1,996.4 2.6% 0.9% - 4.3%

Laboratory, X-ray and Imaging Services 16 409 $366.4 $37,114.5 $36.1 $2,441.9 1.5% 0.9% - 2.1%

Capitated Care/Fixed Payments 0 2,990 $0.0 $533,747,111.4 $0.0 $32,210.5 0.0% N/A

Crossover Claims 0 819 $0.0 $624,806.8 $0.0 $7,048.6 0.0% N/A

Denied Claims 0 732 $0.0 $0.0 $0.0 $0.0 N/A N/A

Hospice Services 0 89 $0.0 $329,008.2 $0.0 $1,989.5 0.0% N/A

Total 663 23,682 $574,822.3 $590,002,508.5 $6,813.2 $353,152.8 1.9% 1.5% - 2.3%

Note: Details do not always sum to the total due to rounding. Additionally, for denied claims or categories with fewer than two claims per sample stratum, a confidence interval is not calculated.

Medicaid FFS Data Processing Payment Errors

Table S13. Summary of Medicaid FFS Data Processing Overall Improper Payments


Error Type

Number of



Sample Paid Amount


Lower Confidence

Limit (millions)

Upper Confidence

Limit (millions)

Provider Information/Enrollment Error (DP10)

2,532 $8,341,821.0 $8,341,834.2 $37,484.8 $33,166.3 $41,803.2


Data Entry Error (DP7) 7 $3,167.9 $10,504.9 $408.4 -$388.1 $1,204.9 Third-party Liability Error (DP4) 9 $9,225.3 $10,355.4 $268.0 -$23.6 $559.6

Pricing Error (DP5) 96 $35,895.4 $252,277.8 $184.6 $114.0 $255.1


Duplicate Claim (DP1) 2 $9,868.0 $9,868.0 $54.7 -$52.4 $161.8 FFS Payment for Managed Care Service (DP3) 2 $5,117.6 $5,117.6 $14.1 -$10.0 $38.3


Claim Filed Untimely (DP11) 1 $2,928.6 $2,928.6 $4.1 N/A N/A Data Processing Technical Deficiency (DTD) 232 $0.0 $379,881.6 $0.0 $0.0 $0.0

Total 3,011 $8,564,510.7 $590,002,508.5 $39,112.0 $34,711.3 $43,512.7 Note: Details do not always sum to the total due to rounding. Additionally, for error types with fewer than two claims per sample stratum, a confidence interval is not calculated.

Table S14. Summary of Medicaid FFS Data Processing Overpayments

Error Type

Number of



Sample Paid Amount


Lower Confidence

Limit (millions)

Upper Confidence

Limit (millions)


2,532 $8,341,821.0 $8,341,834.2 $37,484.8 $33,166.3 $41,803.2


Third-party Liability Error (DP4) 9 $9,225.3 $10,355.4 $268.0 -$23.6 $559.6

Pricing Error (DP5) 69 $30,326.1 $252,277.8 $170.9 $102.1 $239.6



Error Type

Number of



Sample Paid Amount


Lower Confidence

Limit (millions)

Upper Confidence

Limit (millions)

Duplicate Claim (DP1) 2 $9,868.0 $9,868.0 $54.7 -$52.4 $161.8 FFS Payment for Managed Care Service (DP3) 2 $5,117.6 $5,117.6 $14.1 -$10.0 $38.3


Claim Filed Untimely (DP11) 1 $2,928.6 $2,928.6 $4.1 N/A N/A

Data Entry Error (DP7) 4 $2,069.6 $10,504.9 $1.9 -$0.3 $4.1 Data Processing Technical Deficiency (DTD) 232 $0.0 $379,881.6 $0.0 $0.0 $0.0

Total 2,980 $8,557,841.0 $590,002,508.5 $38,690.9 $34,362.9 $43,018.9 Note: Details do not always sum to the total due to rounding. Additionally, for error types with fewer than two claims per sample stratum, a confidence interval is not calculated.

Table S15. Summary of Medicaid FFS Data Processing Underpayments

Error Type

Number of



Sample Paid Amount


Lower Confidence

Limit (millions)

Upper Confidence

Limit (millions)

Data Entry Error (DP7) 3 $1,098.3 $10,504.9 $406.5 -$389.9 $1,203.0

Pricing Error (DP5) 27 $5,569.3 $252,277.8 $13.7 -$2.0 $29.5

System Logic Edit Error (DP6) 1 $2.2 $226.6 $0.8 N/A N/A

Duplicate Claim (DP1) 0 $0.0 $9,868.0 $0.0 N/A N/A Non-covered Service/Recipient (DP2) 0 $0.0 $153,518.0 $0.0 N/A N/A

Third-party Liability Error (DP4) 0 $0.0 $10,355.4 $0.0 N/A N/A


0 $0.0 $8,341,834.2 $0.0 N/A N/A

Claim Filed Untimely (DP11) 0 $0.0 $2,928.6 $0.0 N/A N/A

Administrative/Other (DP12) 0 $0.0 $2,740.3 $0.0 N/A N/A Data Processing Technical Deficiency (DTD) 0 $0.0 $379,881.6 $0.0 N/A N/A

FFS Payment for Managed Care Service (DP3) 0 $0.0 $5,117.6 $0.0 N/A N/A

Total 31 $6,669.7 $590,002,508.5 $421.1 -$375.6 $1,217.7 Note: Details do not always sum to the total due to rounding. Additionally, for error types with fewer than two claims per sample stratum, a confidence interval is not calculated.

Data Processing Payment Errors: Provider Information/Enrollment Error (DP10)

Table S16. Specific Causes of Provider Information/Enrollment Error (DP10)


Cause of Error

Number of Sample

Improper Payments



Lower Confidence

Limit (millions)

Upper Confidence

Limit (millions)

Attending or rendering provider required but not listed on institutional claim 619 $3,036,551.6 $17,008.0 $14,912.5 $19,103.5

Provider not screened using ACA risk based criteria 257 $280,459.2 $3,446.4 $2,580.2 $4,312.6 Attending provider NPI required, but not submitted on institutional claim 352 $1,551,364.1 $3,280.5 $2,782.6 $3,778.3

New provider was not enrolled using ACA risk-based criteria 315 $630,029.9 $2,755.3 $1,919.3 $3,591.2

Referring/ordering provider required but not listed on the claim 246 $163,876.8 $2,539.3 $1,388.5 $3,690.2

Provider not enrolled in Medicaid/CHIP 103 $714,957.4 $2,312.5 $1,022.8 $3,602.3

Referring/ordering provider not enrolled 125 $65,149.9 $2,098.4 $814.5 $3,382.4

Prior authorization was required or not current for DOS 12 $3,348.2 $1,794.9 -$982.2 $4,572.0 Referring/Ordering/Prescribing provider NPI required, but not listed on claim 285 $100,309.0 $1,608.1 $1,088.7 $2,127.5

Attending/rendering provider not enrolled 127 $1,658,991.3 $170.7 $86.5 $254.9

Referring/Ordering/Prescribing provider not enrolled 37 $19,545.1 $140.4 $61.9 $218.9

Billing provider NPI required but not listed on claim 21 $32,468.5 $99.5 $8.7 $190.2

Other 9 $18,185.3 $53.2 $16.1 $90.4 Required Prior authorization missing or not current for DOS 8 $10,403.9 $52.7 $11.7 $93.8

CLIA certification not current for DOS 1 $41.3 $48.3 N/A N/A

Provider license not current for DOS 9 $35,890.6 $43.8 -$2.6 $90.3

Required provider license was not current for DOS 3 $19,983.7 $25.2 -$6.8 $57.2

Billing provider not enrolled 2 $150.8 $4.9 -$4.2 $14.0


Cause of Error

Number of Sample

Improper Payments



Lower Confidence

Limit (millions)

Upper Confidence

Limit (millions)

Rendering provider NPI required, but not submitted on professional claim 1 $114.5 $2.5 N/A N/A

Total 2,532 $8,341,821.0 $37,484.8 $33,166.3 $41,803.2 Note: Details do not always sum to the total due to rounding. Additionally, for error causes with fewer than two claims per sample stratum, a confidence interval is not calculated.

Table S17. Specific Sub-Causes of Provider Information/Enrollment Error (DP10)

Cause of Error Sub-Cause of Error Count of Errors

Provider not screened using ACA risk based criteria No required databases were checked prior to enrollment 186

Provider not screened using ACA risk based criteria Newly enrolled after 3/24/11 (or date allowed by SPA) 170

Provider not screened using ACA risk based criteria System for Award Management (SAM) or Excluded Parties List System (EPLS) not checked prior to enrollment 54

Provider not screened using ACA risk based criteria Social Security Death Master File (DMF) was not checked prior to enrollment 31

Provider not screened using ACA risk based criteria OIG LEIE database was not checked prior to enrollment 25

Provider not screened using ACA risk based criteria On-site visit not conducted for moderate or high risk levels prior to enrollment 14

Provider not screened using ACA risk based criteria National Plan and Provider Enumeration System (NPPES) not checked prior to enrollment 11

Note: It is possible for one claim to have multiple sub-causes for error. Therefore, one claim may be counted multiple times in this table.

Data Processing Payment Errors: Non-covered Service/Recipient Error (DP2)

Table S18. Specific Causes of Non-covered Service/Recipient Error (DP2)


Cause of Error

Number of Sample

Improper Payments



Lower Confidence

Limit (millions)

Upper Confidence

Limit (millions)

Other 63 $85,115.9 $276.5 $177.8 $375.3 Recipient was ineligible for the applicable program on DOS 49 $68,280.9 $265.6 $111.4 $419.8

HCBS service not approved by recipient’s service plan 3 $84.1 $52.8 -$21.7 $127.2

Non-covered based on recipient’s benefit plan 2 $37.1 $7.5 -$4.6 $19.5

Total 117 $153,518.0 $602.3 $404.3 $800.4 Note: Details do not always sum to the total due to rounding. Additionally, for error causes with fewer than two claims per sample stratum, a confidence interval is not calculated.

Data Processing Payment Errors: Data Entry Error (DP7)

Table S19. Specific Causes of Data Entry Error (DP7)

Cause of Error

Number of Sample

Improper Payments



Lower Confidence

Limit (millions)

Upper Confidence

Limit (millions)

Other 1 $902.4 $406.4 N/A N/A

Incorrect data entry made from paper claim 3 $1,273.7 $1.2 -$0.6 $3.0

Rates incorrectly entered into system rate file 3 $991.9 $0.8 -$0.5 $2.2

Total 7 $3,167.9 $408.4 -$388.1 $1,204.9 Note: Details do not always sum to the total due to rounding. Additionally, for error causes with fewer than two claims per sample stratum, a confidence interval is not calculated.

Medicaid FFS Data Processing Errors by Service Type

Table S20. Medicaid FFS Data Processing Error by Service Type


Category

Number of


Number of

Claims Sampled


Sample Paid Amount


Projected Paid

Amount (millions)

Improper Payment

Rate 95% CI

Nursing Facility, Intermediate Care Facilities 632 2,769 $2,001,613.3 $11,145,536.0 $10,629.4 $71,090.6 15.0% 12.7% - 17.2%

Prescribed Drugs 509 2,734 $413,911.7 $2,464,847.5 $5,623.0 $34,045.6 16.5% 11.8% - 21.2%

ICF for Individuals with Intellectual Disabilities and Group Homes 346 734 $3,671,705.0 $7,941,626.6 $4,980.4 $11,542.1 43.2% 38.5% - 47.8%

Habilitation and Waiver Programs, School Services 315 3,230 $225,145.1 $4,054,734.2 $4,183.9 $52,199.6 8.0% 5.6% - 10.4%

Personal Support Services 159 1,169 $53,094.6 $356,370.1 $4,072.8 $26,780.0 15.2% 5.6% - 24.8%

Inpatient and Outpatient Hospital 241 3,171 $1,333,021.9 $24,954,982.9 $2,228.0 $52,573.6 4.2% 3.3% - 5.2%

Psychiatric, Mental Health, and Behavioral Health Services 159 1,379 $598,942.6 $3,381,189.4 $1,740.5 $19,677.1 8.8% 5.4% - 12.3%

Clinics 60 652 $35,167.9 $251,343.5 $1,327.3 $9,057.9 14.7% 7.4% - 21.9%

Home Health Services 67 382 $18,861.9 $231,607.6 $831.6 $7,021.4 11.8% 7.6% - 16.0%

Hospice Services 13 89 $54,311.7 $329,008.2 $815.3 $1,989.5 41.0% 26.9% - 55.0%


61 273 $25,408.8 $120,626.1 $488.4 $3,440.9 14.2% 11.2% - 17.2%

Dental and Other Oral Surgery Services 114 681 $13,416.3 $80,303.4 $425.6 $5,839.1 7.3% 5.1% - 9.4%


Crossover Claims 79 819 $78,268.2 $624,806.8 $385.5 $7,048.6 5.5% 2.7% - 8.2%

Laboratory, X-ray and Imaging Services 97 409 $5,907.9 $37,114.5 $365.5 $2,441.9 15.0% 10.9% - 19.1%


Category

Number of


Number of

Claims Sampled


Sample Paid Amount


Projected Paid

Amount(millions)

Improper Payment

Rate95% CI

Physicians and Other Licensed Practitioner Services 65 967 $8,291.5 $195,748.0 $232.9 $11,267.7 2.1% 1.0% - 3.1%


34 222 $1,365.2 $17,119.6 $207.4 $1,996.4 10.4% 5.5% - 15.3%

Capitated Care/Fixed Payments 28 2,990 $20,850.1 $533,747,111.4 $116.5 $32,210.5 0.4% 0.0% - 0.7%

Transportation and Accommodations 28 280 $4,316.4 $68,432.7 $50.8 $2,930.4 1.7% 0.8% - 2.7%

Total 3,011 23,682 $8,564,510.7 $590,002,508.5 $39,112.0 $353,152.8 11.1% 9.9% - 12.2%


Medicaid Managed Care Component Improper Payment Rate

Table S21. Medicaid Managed Care Data Processing Improper Payment Rates by State


State

Number of Sample

Improper Payments


Sample Paid Amount

Improper Payment Rate 95% CI

National 25 $35,771.3 $10,271,730.0 0.3% 0.1% - 0.4%

Cycle 1 - ST1 8 $3,351.2 $230,655.7 3.0% 0.4% - 5.6%

Cycle 1 - ST2 3 $1,474.1 $282,676.5 1.5% ( 0.5%) - 3.5%

Cycle 2 - ST3 2 $445.1 $204,870.2 1.1% ( 0.4%) - 2.6%

Cycle 3 - ST4 2 $7,114.7 $174,924.7 1.0% ( 0.4%) - 2.5%

Cycle 1 - ST5 2 $286.2 $228,717.9 0.9% ( 0.3%) - 2.1%

Cycle 2 - ST6 1 $263.6 $292,633.1 0.5% ( 0.5%) - 1.6%

Cycle 2 - ST7 1 $5,579.0 $346,634.8 0.5% ( 0.5%) - 1.5%

Cycle 3 - ST8 1 $937.3 $212,318.0 0.4% ( 0.4%) - 1.1%

Cycle 2 - ST9 1 $6,500.4 $302,004.3 0.4% ( 0.3%) - 1.1%

Cycle 3 - ST10 1 $2,960.5 $260,946.0 0.3% ( 0.3%) - 0.9%

Cycle 1 - ST11 2 $3,640.8 $348,776.8 0.3% ( 0.3%) - 0.9%

Cycle 3 - ST12 1 $3,218.4 $325,966.7 0.2% ( 0.2%) - 0.7%

Cycle 3 - ST13 0 $0.0 $270,025.9 0.0% 0.0% - 0.0%

Cycle 2 - ST14 0 $0.0 $211,846.8 0.0% 0.0% - 0.0%

Cycle 2 - ST15 0 $0.0 $188,268.6 0.0% 0.0% - 0.0%

Cycle 1 - ST16 0 $0.0 $557,199.4 0.0% 0.0% - 0.0%

Cycle 3 - ST17 0 $0.0 $277,547.6 0.0% 0.0% - 0.0%

Cycle 1 - ST18 0 $0.0 $31,176.3 0.0% 0.0% - 0.0%

Cycle 3 - ST19 0 $0.0 $56,137.1 0.0% 0.0% - 0.0%

Cycle 3 - ST20 0 $0.0 $42,530.1 0.0% 0.0% - 0.0%

Cycle 1 - ST21 0 $0.0 $549,172.2 0.0% 0.0% - 0.0%

Cycle 2 - ST22 0 $0.0 $160,030.7 0.0% 0.0% - 0.0%

Cycle 2 - ST23 0 $0.0 $511,274.9 0.0% 0.0% - 0.0%

Cycle 2 - ST24 0 $0.0 $254,982.3 0.0% 0.0% - 0.0%

Cycle 1 - ST25 0 $0.0 $239,387.6 0.0% 0.0% - 0.0%

Cycle 3 - ST26 0 $0.0 $123,272.7 0.0% 0.0% - 0.0%

Cycle 1 - ST27 0 $0.0 $323,977.2 0.0% 0.0% - 0.0%

Cycle 2 - ST28 0 $0.0 $292,069.1 0.0% 0.0% - 0.0%

Cycle 3 - ST29 0 $0.0 $105,812.3 0.0% 0.0% - 0.0%


State

Number of Sample

Improper Payments


Sample Paid Amount


Cycle 2 - ST30 0 $0.0 $343,200.7 0.0% 0.0% - 0.0%

Cycle 1 - ST31 0 $0.0 $283,845.9 0.0% 0.0% - 0.0%

Cycle 3 - ST32 0 $0.0 $368,665.5 0.0% 0.0% - 0.0%

Cycle 1 - ST33 0 $0.0 $301,457.8 0.0% 0.0% - 0.0%

Cycle 1 - ST34 0 $0.0 $217,796.4 0.0% 0.0% - 0.0%

Cycle 2 - ST35 0 $0.0 $212,644.6 0.0% 0.0% - 0.0%

Cycle 3 - ST36 0 $0.0 $182,412.2 0.0% 0.0% - 0.0%

Cycle 2 - ST37 0 $0.0 $226,576.6 0.0% 0.0% - 0.0%

Cycle 3 - ST38 0 $0.0 $128,513.3 0.0% 0.0% - 0.0%

Cycle 2 - ST39 0 $0.0 $187,190.5 0.0% 0.0% - 0.0%

Cycle 1 - ST40 0 $0.0 $413,591.2 0.0% 0.0% - 0.0% Note: Details do not always sum to the total due to rounding.

Medicaid Managed Care Errors by Type of Error

Table S22. Summary of Medicaid Managed Care Data Processing Projected Dollars by Type of Error

Error Type

Number of



Sample Paid Amount


Lower Confidence

Limit (millions)

Upper Confidence

Limit (millions)

Non-covered Service/Recipient (DP2) 19 $20,782.2 $20,782.2 $495.6 $209.0 $782.2 Provider Information/Enrollment Error (DP10) 2 $1,265.0 $1,265.0 $43.4 -$17.0 $103.8


Managed Care Rate Cell Error (DP8) 1 $937.3 $1,118.5 $13.3 N/A N/A Data Processing Technical Deficiency (DTD) 1 $0.0 $0.0 $0.0 N/A N/A

Total 25 $35,771.3 $10,271,730.0 $581.4 $284.6 $878.2 Note: Details do not always sum to the total due to rounding. Additionally, for error types with fewer than two claims per sample stratum, a confidence interval is not calculated.

Medicaid Managed Care Data Processing Payment Errors

Table S23. Summary of Medicaid Managed Care Data Processing Overpayments


Error Type

Number of



Sample Paid Amount


Lower Confidence

Limit (millions)

Upper Confidence

Limit (millions)



2 $1,265.0 $1,265.0 $43.4 -$17.0 $103.8

Duplicate Claim (DP1) 2 $12,786.9 $12,786.9 $29.2 -$11.3 $69.7 Managed Care Rate Cell Error (DP8) 1 $937.3 $1,118.5 $13.3 N/A N/A

Data Processing Technical Deficiency (DTD) 1 $0.0 $0.0 $0.0 N/A N/A


Table S24. Summary of Medicaid Managed Care Data Processing Underpayments

Error Type

Number of



Sample Paid Amount


Lower Confidence

Limit (millions)

Upper Confidence

Limit (millions)


Managed Care Rate Cell Error (DP8) 0 $0.0 $1,118.5 $0.0 N/A N/A


0 $0.0 $1,265.0 $0.0 N/A N/A

Data Processing Technical Deficiency (DTD) 0 $0.0 $0.0 $0.0 N/A N/A



Table S25. Specific Causes of Non-covered Service/Recipient Error (DP2)


Cause of Error

Number of




Lower Confidence

Limit (millions)

Upper Confidence

Limit (millions)

Recipient was ineligible for the applicable program on DOS 18 $17,141.4 $445.1 $176.1 $714.2

Claim/Capitation payment paid for coverage period or Date of Service after recipient’s date of death

1 $3,640.8 $50.4 N/A N/A



Table S26. Specific Causes of Provider Information/Enrollment Error (DP10)

Cause of Error

Number of




Lower Confidence

Limit (millions)

Upper Confidence

Limit (millions)

Billing provider not enrolled 2 $1,265.0 $43.4 -$17.0 $103.8

Total 2 $1,265.0 $43.4 -$17.0 $103.8 Note: Details do not always sum to the total due to rounding. Additionally, for error causes with fewer than two claims per sample stratum, a confidence interval is not calculated.

Data Processing Payment Errors: Duplicate Claim Error (DP1)

Table S27. Specific Causes of Duplicate Claim Error (DP1)


Cause of Error

Number of




Lower Confidence

Limit (millions)

Upper Confidence

Limit (millions)

Sampled claim is a duplicate of a previously paid claim 2 $12,786.9 $29.2 -$11.3 $69.7

Total 2 $12,786.9 $29.2 -$11.3 $69.7 Note: Details do not always sum to the total due to rounding. Additionally, for error causes with fewer than two claims per sample stratum, a confidence interval is not calculated.

Appendix 3: CHIP Trending for Cycle-Specific and National Rolling Improper Payment Rates

Table B1. Inception to Date Cycle-Specific CHIP Component Improper Payment Rates



2012 6.9% 0.1% 5.7% 8.2% 2013 6.1% 0.5% 4.4% 6.8% 2014 6.2% 0.0% 2.6% 4.8% 2015 13.1% 0.6% N/A* N/A* 2016 14.0% 3.7% N/A* N/A*

*For the 2015 and 2016 measurements, eligibility reviews are suspended. Therefore, eligibility component improper payment rates have been removed for the 2015 and 2016 rates. **The overall estimate is comprised of the weighted sum of the FFS and managed care components, plus the eligibility component, minus a small adjustment to account for the overlap between the claims and eligibility review functions. From 2007-2013, the cycle-specific rate is calculated using data from the 17 states sampled and projected to the national level. From 2014 onward, the cycle-specific rate represents only the 17 states sampled.

Table B2. National Rolling CHIP Component Improper Payment Rates


2013 Rolling Rates 5.7% 0.2% 5.1% 7.1% 2014 Rolling Rates 6.2% 0.2% 4.2% 6.5% 2015 Rolling Rates 7.3% 0.4% 4.2%* 6.8% 2016 Rolling Rates 10.2% 1.0% 4.2%* 8.0%

*Rolling eligibility component statistics for 2015 and 2016 reflect the latest eligibility results from the most recent cycles prior to the eligibility freeze. **The overall estimate is comprised of the weighted sum of the FFS and managed care components, plus the eligibility component, minus a small adjustment to account for the overlap between the claims and eligibility review functions. It is important to note that the 2013 rolling rate for CHIP represents 2 cycles since only 34 states had been sampled at the time.

Appendix 4: CHIP Supplemental Information

CMS reported a rolling improper payment rate for CHIP in 2016 based on the 51 states reviewed from 2014-2016. Unless otherwise noted, all tables and figures in Appendix 4 are based on the rolling rate. There was no eligibility component review from 2015-2016 and eligibility results from the most recent cycles prior to the eligibility freeze are used as a proxy in the overall improper payment rate calculation.

List of Tables

Table T1. Summary of CHIP Projected Improper Payments ....................................................................... 30 Table T2. Summary of Projected CHIP Overpayments................................................................................ 30 Table T3. Summary of Projected CHIP Underpayments ............................................................................. 31 Table T4. CHIP FFS Medical Review and Data Processing Improper Payment Rates by State ................... 31 Table T5. Summary of CHIP FFS Projected Dollars by Type of Error ........................................................... 33 Table T6. Summary of CHIP FFS Medical Review Overall Errors ................................................................. 34 Table T7. Summary of CHIP FFS Medical Review Overpayments ............................................................... 34 Table T8. Summary of CHIP FFS Medical Review Underpayments ............................................................. 35 Table T9. Specific Causes of Incomplete Documentation Error (MR2) ....................................................... 36 Table T10. Specific Causes of No Documentation Error (MR1) .................................................................. 37 Table T11. Specific Causes of Number of Unit(s) Error (MR6) .................................................................... 37 Table T12. CHIP FFS Medical Review Error by Service Type ....................................................................... 38 Table T13. Summary of CHIP FFS Data Processing Overall Improper Payments ........................................ 40 Table T14. Summary of CHIP FFS Data Processing Overpayments ............................................................. 40 Table T15. Summary of CHIP FFS Data Processing Underpayments ........................................................... 41 Table T16. Specific Causes of Provider Information/Enrollment Error (DP10) ........................................... 42 Table T17. Specific Sub-Causes of Provider Information/Enrollment Error (DP10) .................................... 43 Table T18. Specific Causes of Non-covered Service/Recipient Error (DP2) ................................................ 44 Table T19. Specific Causes of Administrative/Other Error (DP12) .............................................................. 44 Table T20. CHIP FFS Data Processing Error by Service Type ....................................................................... 45 Table T21. CHIP Managed Care Data Processing Improper Payment Rates by State ................................. 47 Table T22. Summary of CHIP Managed Care Data Processing Projected Dollars by Type of Error ............ 48 Table T23. Summary of CHIP Managed Care Data Processing Overpayments ........................................... 49 Table T24. Summary of CHIP Managed Care Data Processing Underpayments ......................................... 49 Table T25. Specific Causes of Non-covered Service/Recipient Error (DP2) ................................................ 50 Table T26. Specific Causes of Managed Care Rate Cell Error (DP8) ............................................................ 50 Table T27. Specific Causes of Third-party Liability Error (DP4) ................................................................... 51


CHIP Overpayments and Underpayments

Table T1. Summary of CHIP Projected Improper Payments


Category

Number of


Number of

Claims Sampled


Sample Paid Amount


Projected Paid

Amount (millions)

Improper Payment

Rate 95% CI

FFS 3,494 21,212 $3,955,395.3 $61,545,904.1 $433.5 $4,269.3 10.2% 9.3% - 11.0%

FFS Medical Review 751 21,212 $414,465.2 $61,545,904.1 $94.9 $4,269.3 2.2% 1.9% - 2.5%

FFS Data Processing 2,888 21,212 $3,596,947.8 $61,545,904.1 $355.8 $4,269.3 8.3% 7.6% - 9.1%

Managed Care 245 9,350 $156,983.8 $2,063,104.1 $91.7 $9,072.4 1.0% 0.7% - 1.3%

Eligibility 1,841 25,358 $240,621.1 $5,617,602.3 $562.8 $13,341.7 4.2% 3.7% - 4.8%

Total 5,580 55,920 $4,353,000.3 $69,226,610.5 $1,065.8 $13,341.7 8.0% 7.4% - 8.6% Note: Details do not always sum to the total due to rounding. Eligibility component statistics reflect the most recent eligibility calculations prior to 2016.

Table T2. Summary of Projected CHIP Overpayments

Category

Number of


Number of

Claims Sampled


Sample Paid Amount


Projected Paid

Amount (millions)

Improper Payment

Rate 95% CI

FFS 3,415 21,212 $3,953,496.4 $61,545,904.1 $431.1 $4,269.3 10.1% 9.3% - 10.9%

FFS Medical Review 750 21,212 $414,449.4 $61,545,904.1 $94.8 $4,269.3 2.2% 1.9% - 2.5%

FFS Data Processing 2,808 21,212 $3,595,064.6 $61,545,904.1 $353.5 $4,269.3 8.3% 7.5% - 9.1%

Managed Care 170 9,350 $156,962.0 $2,063,104.1 $91.7 $9,072.4 1.0% 0.7% - 1.3%

Eligibility 1,753 25,358 $238,406.1 $5,617,602.3 $556.9 $13,341.7 4.2% 3.6% - 4.7%

Total 5,338 55,920 $4,348,864.5 $69,226,610.5 $1,057.8 $13,341.7 7.9% 7.3% - 8.5%


Table T3. Summary of Projected CHIP Underpayments


Category

Number of


Number of

Claims Sampled


Sample Paid Amount


Projected Paid

Amount (millions)

Improper Payment

Rate 95% CI

FFS 81 21,212 $1,899.0 $61,545,904.1 $2.4 $4,269.3 0.1% ( 0.0%) - 0.1%

FFS Medical Review 1 21,212 $15.8 $61,545,904.1 $0.1 $4,269.3 0.0% ( 0.0%) -

0.0% FFS Data Processing 80 21,212 $1,883.2 $61,545,904.1 $2.3 $4,269.3 0.1% ( 0.0%) -

0.1%

Managed Care 75 9,350 $21.8 $2,063,104.1 $0.0 $9,072.4 0.0% ( 0.0%) - 0.0%

Eligibility 88 25,358 $2,215.0 $5,617,602.3 $5.9 $13,341.7 0.0% 0.0% - 0.1%

Total 244 55,920 $4,135.8 $69,226,610.5 $8.3 $13,341.7 0.1% 0.0% - 0.1%


CHIP FFS Component Improper Payment Rate

Table T4. CHIP FFS Medical Review and Data Processing Improper Payment Rates by State

State


Sample Paid Amount


Rate

Number of



Improper Payment

Rate

Number of



Improper Payment

Rate

National 751 $414,465.2 2.2% 2,888 $3,596,947.8 8.3% $61,545,904.1 10.2%

Cycle 3 - ST1 7 $55.0 0.3% 439 $49,352.8 59.7% $187,879.8 59.7%

Cycle 3 - ST2 0 $0.0 0.0% 90 $152,222.5 52.5% $630,405.8 52.5%

Cycle 1 - ST3 90 $56,180.2 11.3% 300 $684,768.4 32.2% $1,456,328.9 37.7%

Cycle 3 - ST4 6 $671.5 0.9% 38 $68,218.4 36.7% $340,199.7 37.3%

Cycle 1 - ST5 1 $158.2 0.3% 76 $3,676.6 25.5% $394,233.1 25.8%

Cycle 3 - ST6 8 $5,768.7 1.7% 88 $100,112.4 20.4% $594,648.8 22.0%

Cycle 1 - ST7 11 $4,199.0 2.3% 74 $41,707.5 20.3% $557,029.4 21.6%

Cycle 1 - ST8 2 $845.8 0.7% 65 $258,209.6 20.1% $1,933,739.9 20.8%

Cycle 3 - ST9 41 $4,462.7 3.4% 93 $335,636.7 17.5% $1,579,481.9 20.3%

Cycle 2 - ST10 28 $32,590.9 10.2% 63 $104,083.3 6.6% $481,681.4 16.8%

Cycle 3 - ST11 27 $12,369.7 11.8% 34 $1,905.1 4.6% $543,254.1 15.6%


State


Sample Paid Amount


Rate

Number of



Improper Payment

Rate

Number of



Improper Payment

Rate

Cycle 3 - ST12 159 $212,606.6 7.3% 178 $550,358.9 8.1% $3,999,992.1 14.5%

Cycle 2 - ST13 10 $3,866.3 2.8% 58 $253,689.5 11.8% $974,013.1 14.2%

Cycle 1 - ST14 18 $1,376.5 1.8% 153 $49,786.8 11.6% $20,380,791.1 13.0%

Cycle 1 - ST15 0 $0.0 0.0% 53 $8,044.2 12.5% $351,446.4 12.5%

Cycle 3 - ST16 27 $11,895.4 5.2% 19 $11,535.4 6.4% $460,047.8 11.5%

Cycle 1 - ST17 56 $16,017.1 4.5% 75 $14,813.8 7.2% $1,967,884.9 11.2%

Cycle 2 - ST18 20 $617.2 1.2% 116 $45,812.7 9.4% $271,458.8 10.2%

Cycle 1 - ST19 4 $183.9 1.3% 50 $11,276.5 9.7% $4,339,515.4 9.7%

Cycle 3 - ST20 5 $1,257.1 1.7% 29 $5,922.5 8.1% $769,291.1 9.6%

Cycle 3 - ST21 9 $4,449.8 1.5% 26 $84,701.9 7.7% $676,183.3 9.1%

Cycle 3 - ST22 17 $2,860.0 1.3% 36 $8,786.3 7.1% $1,072,591.1 8.4%

Cycle 1 - ST23 12 $2,697.7 5.7% 17 $1,986.6 2.7% $509,909.9 8.4%

Cycle 2 - ST24 18 $1,605.2 3.2% 27 $5,926.2 4.5% $202,315.2 7.8%

Cycle 2 - ST25 13 $956.0 3.9% 160 $20,576.1 3.4% $176,824.9 6.8%

Cycle 1 - ST26 6 $440.9 0.7% 28 $277,371.0 5.6% $1,405,834.6 6.3%

Cycle 1 - ST27 38 $26,632.0 2.9% 58 $20,458.8 3.4% $2,532,518.7 6.3%

Cycle 3 - ST28 9 $1,232.4 2.2% 15 $85,163.4 4.3% $552,184.2 6.2%

Cycle 2 - ST29 2 $1.0 0.0% 35 $24,578.7 6.1% $463,412.6 6.2%

Cycle 1 - ST30 3 $301.2 0.2% 38 $12,100.6 5.8% $617,684.1 6.0%

Cycle 2 - ST31 15 $960.8 2.2% 26 $18,095.0 4.0% $625,489.2 6.0%

Cycle 2 - ST32 16 $230.8 0.5% 22 $50,990.8 5.0% $995,600.1 5.5%

Cycle 2 - ST33 7 $969.6 0.3% 38 $36,526.9 4.5% $194,127.8 4.8%

Cycle 2 - ST34 19 $2,811.1 2.5% 32 $19,239.3 2.0% $182,546.6 4.5%

Cycle 2 - ST35 3 $124.0 0.0% 10 $12,738.3 4.3% $418,529.4 4.3%

Cycle 1 - ST36 3 $226.7 0.5% 32 $10,540.9 3.1% $317,287.5 3.6%

Cycle 1 - ST37 3 $33.2 0.2% 26 $9,379.0 3.2% $430,706.7 3.4%

Cycle 3 - ST38 6 $192.1 0.1% 53 $19,804.0 3.1% $4,620,553.7 3.1%

Cycle 2 - ST39 5 $74.3 0.3% 24 $26,694.5 2.7% $477,932.0 3.0%

Cycle 2 - ST40 11 $791.7 1.0% 21 $16,980.8 1.9% $289,014.9 2.6%


State


Sample Paid Amount


Rate

Number of



Improper Payment

Rate

Number of



Improper Payment

Rate

Cycle 3 - ST41 2 $158.1 0.2% 5 $959.6 2.2% $474,575.5 2.2%

Cycle 2 - ST42 4 $299.3 1.1% 13 $2,461.4 0.9% $648,537.9 2.0%

Cycle 3 - ST43 4 $814.4 0.4% 8 $74,394.9 0.6% $504,981.5 1.1%

Cycle 2 - ST44 4 $447.9 0.0% 35 $5,153.5 1.0% $317,030.5 1.0%

Cycle 2 - ST45 2 $33.4 0.1% 12 $206.2 0.4% $626,208.6 0.5%

CHIP FFS Payment Errors by Type of Error

Table T5. Summary of CHIP FFS Projected Dollars by Type of Error

Error Type

Number of



Sample Paid Amount


Lower Confidence

Limit (millions)

Upper Confidence

Limit (millions)

Provider Information/Enrollment Error (DP10) 1,586 $2,873,250.3 $2,873,246.2 $293.7 $258.5 $328.9

Incomplete Documentation (MR2) 408 $199,951.6 $199,953.4 $58.5 $47.6 $69.5


No Documentation (MR1) 211 $186,520.6 $186,526.7 $29.0 $22.2 $35.8

Administrative/Other (DP12) 19 $2,457.4 $2,454.9 $5.7 $0.3 $11.0

Pricing Error (DP5) 137 $37,413.8 $1,020,724.1 $3.0 $1.3 $4.6

Number of Unit(s) Error (MR6) 30 $17,150.8 $20,746.4 $2.6 $0.1 $5.0

Third-party Liability Error (DP4) 17 $761.7 $732.0 $2.5 -$1.1 $6.2

Procedure Coding Error (MR3) 8 $3,165.4 $4,354.7 $1.4 $0.1 $2.6


Administrative/Other (MR10) 9 $2,387.8 $2,387.8 $1.1 $0.2 $2.0


Duplicate Claim (DP1) 10 $50,551.0 $50,551.0 $1.0 $0.0 $1.9

Data Entry Error (DP7) 40 $32,258.0 $38,019.7 $0.9 -$0.2 $1.9 FFS Payment for Managed Care Service (DP3) 3 $320.3 $320.3 $0.2 -$0.1 $0.6

Claim Filed Untimely (DP11) 3 $15,465.1 $15,465.1 $0.2 $0.0 $0.4


Error Type

Number of



Sample Paid Amount


Lower Confidence

Limit (millions)

Upper Confidence

Limit (millions)


Unbundling (MR5) 2 $184.8 $184.8 $0.1 -$0.1 $0.3

Diagnosis Coding Error (MR4) 2 $160.0 $160.0 $0.1 $0.0 $0.1 Data Processing Technical Deficiency (DTD) 317 $0.0 $2,825,338.7 $0.0 $0.0 $0.0


Total 3,494 $3,955,395.3 $61,545,904.1 $433.5 $394.5 $472.4 Note: Details do not always sum to the total due to rounding. This table assumes one error per claim, which means that claims that have DP and MR errors simultaneously are accounted for once. The purpose of this table is to show the total error found per claim and will not necessarily match other tables in this report that only report one type of review error. Additionally, for error types with fewer than two claims per sample stratum, a confidence interval is not calculated.

CHIP FFS Medical Review Payment Errors

Table T6. Summary of CHIP FFS Medical Review Overall Errors

Error Type

Number of



Sample Paid Amount


Lower Confidence

Limit (millions)

Upper Confidence

Limit (millions)









Unbundling (MR5) 2 $184.8 $184.8 $0.1 -$0.1 $0.3

Diagnosis Coding Error (MR4) 2 $160.0 $160.0 $0.1 $0.0 $0.1



Table T7. Summary of CHIP FFS Medical Review Overpayments


Error Type

Number of



Sample Paid Amount


Lower Confidence

Limit (millions)

Upper Confidence

Limit (millions)









Unbundling (MR5) 2 $184.8 $184.8 $0.1 -$0.1 $0.3

Diagnosis Coding Error (MR4) 2 $160.0 $160.0 $0.1 $0.0 $0.1



Table T8. Summary of CHIP FFS Medical Review Underpayments

Error Type

Number of



Sample Paid Amount


Lower Confidence

Limit (millions)

Upper Confidence

Limit (millions)

Procedure Coding Error (MR3) 1 $15.8 $4,354.7 $0.1 N/A N/A

No Documentation (MR1) 0 $0.0 $186,526.7 $0.0 N/A N/A

Incomplete Documentation (MR2) 0 $0.0 $199,953.4 $0.0 N/A N/A

Diagnosis Coding Error (MR4) 0 $0.0 $160.0 $0.0 N/A N/A

Unbundling (MR5) 0 $0.0 $184.8 $0.0 N/A N/A

Number of Unit(s) Error (MR6) 0 $0.0 $20,746.4 $0.0 N/A N/A


Policy Violation (MR8) 0 $0.0 $2,389.5 $0.0 N/A N/A

Inadequate Documentation (MR9) 0 $0.0 $2,752.4 $0.0 N/A N/A

Administrative/Other (MR10) 0 $0.0 $2,791.3 $0.0 N/A N/A Medical Technical Deficiency (MTD) 0 $0.0 $22,917.6 $0.0 N/A N/A


Medical Review Payment Errors: Incomplete Documentation Error (MR2)

Table T9. Specific Causes of Incomplete Documentation Error (MR2)


Cause of Error

Number of Sample

Improper Payments



Lower Confidence

Limit (millions)

Upper Confidence

Limit (millions)

Provider did not submit the pharmacy signature log and/or documentation of patient counseling 123 $64,065.4 $17.6 $12.0 $23.1

Documentation of patient counseling not provided 78 $12,376.0 $10.2 $6.4 $14.0 Provider did not submit a record with daily documentation of specific tasks performed on the sampled DOS 42 $18,647.7 $10.2 $3.7 $16.7

Required record of recipient acceptance or refusal of medication counseling not provided 32 $23,145.8 $6.1 $2.1 $10.2

Provider did not submit the service plan 24 $17,670.6 $4.1 $1.8 $6.5 Provider did not submit required progress notes applicable to the sampled DOS 24 $8,743.3 $3.6 $1.5 $5.7

Provider did not submit sufficient documentation to support the claim 29 $33,284.2 $3.0 $1.3 $4.8 Individual plan (ISP, ISFP, IEP, or POC,) was present, but not applicable to the sampled DOS 30 $3,188.9 $2.2 $1.0 $3.3

Record does not include a physician’s order for the sampled service 14 $1,309.9 $0.6 $0.1 $1.1 Multiple documents are missing from the record that are required to support payment 5 $2,131.0 $0.3 -$0.1 $0.7

Provider did not submit a valid prescription 2 $13,002.8 $0.2 -$0.1 $0.6

Provider did not submit the face-to-face assessment documentation 2 $323.7 $0.1 -$0.1 $0.3

Provider did not submit the test result 1 $1,999.5 $0.0 N/A N/A

Provider did not submit the required signed timesheet 2 $29.3 $0.0 $0.0 $0.0


Medical Review Payment Errors: No Documentation Error (MR1)

Table T10. Specific Causes of No Documentation Error (MR1)


Cause of Error

Number of Sample Improper Payments



Lower Confidence

Limit (millions)

Upper Confidence

Limit (millions)

Provider did not respond to the request for records 99 $57,646.2 $14.4 $9.7 $19.1 Provider responded with a statement that the recipient was not seen on the sampled DOS 38 $10,879.8 $5.7 $2.5 $9.0

Provider responded that he or she did not have the recipient on file or in the system 27 $110,578.7 $2.9 $1.3 $4.4

State could not locate the provider 11 $1,103.5 $2.2 -$0.5 $5.0

Provider did not document the encounter/billed service 2 $215.4 $0.9 -$0.6 $2.3

Provider responded with a statement that records cannot be located 13 $2,138.2 $0.6 $0.1 $1.2 Provider responded with a statement that there was no documentation for the encounter/billed service 2 $250.6 $0.5 -$0.3 $1.4

Provider responded with a statement that the record is lost or destroyed due to an unforeseeable and uncontrollable event such as fire, flood, or earthquake 2 $140.2 $0.4 -$0.4 $1.2

Provider submitted a record for wrong date of service 1 $29.6 $0.4 N/A N/A Provider responded that he or she is no longer operating business/practice, and the record is unavailable 8 $2,111.2 $0.3 $0.0 $0.6

Other 2 $943.6 $0.2 -$0.2 $0.7

Provider is under fraud investigation 1 $157.0 $0.2 N/A N/A

Provider billed in error 2 $290.7 $0.2 -$0.1 $0.4

Provider did not submit medical records, only billing information 1 $27.1 $0.0 N/A N/A

Provider responded with a statement that he or she billed for the wrong recipient 2 $8.9 $0.0 $0.0 $0.0


Medical Review Payment Errors: Number of Unit(s) Error (MR6)

Table T11. Specific Causes of Number of Unit(s) Error (MR6)


Cause of Error

Number of Sample

Improper Payments



Lower Confidence

Limit (millions)

Upper Confidence

Limit (millions)

Required start and stop times are not included for all sampled DOS 1 $439.6 $1.2 N/A N/A

Number of units billed exceeds number of units authorized 26 $15,080.9 $1.2 $0.4 $2.0

Provider miscalculated the number of units 3 $981.7 $0.2 -$0.1 $0.4


CHIP FFS Medical Review Errors by Service Type

Table T12. CHIP FFS Medical Review Error by Service Type

Category

Number of


Number of

Claims Sampled


Sample Paid Amount


Projected Paid

Amount (millions)

Improper Payment

Rate 95% CI

Prescribed Drugs 297 3,795 $179,113.0 $4,033,435.1 $39.7 $718.5 5.5% 4.4% - 6.7%

Psychiatric, Mental Health, and Behavioral Health Services 94 2,415 $51,277.6 $5,426,701.0 $15.5 $576.0 2.7% 1.9% - 3.5%

Clinics 43 1,101 $15,364.2 $218,812.2 $8.9 $270.2 3.3% 2.1% - 4.5%

Dental and Other Oral Surgery Services 52 2,662 $1,978.2 $432,711.1 $6.7 $696.0 1.0% 0.4% - 1.6%

Physicians and Other Licensed Practitioner Services 62 2,008 $19,002.0 $431,047.3 $6.0 $428.9 1.4% 0.9% - 1.9%

Habilitation and Waiver Programs, School Services 51 1,257 $10,570.3 $926,899.1 $5.8 $150.3 3.9% 2.0% - 5.7%

Inpatient and Outpatient Hospital 45 4,063 $119,922.7 $42,758,800.3 $4.1 $1,029.3 0.4% 0.2% - 0.5%


Category

Number of


Number of

Claims Sampled


Sample Paid Amount


Projected Paid

Amount(millions)

Improper Payment

Rate95% CI


18 552 $2,006.8 $34,140.1 $2.7 $102.1 2.7% 0.5% - 4.9%

Personal Support Services 43 584 $5,723.3 $173,143.3 $2.1 $67.6 3.1% 1.2% - 5.1%

Laboratory, X-ray and Imaging Services 25 605 $3,675.3 $79,087.2 $1.3 $40.1 3.1% 1.7% - 4.6%

Home Health Services 11 317 $3,972.8 $163,306.2 $1.0 $16.7 6.1% ( 1.3%) - 13.4%

Transportation and Accommodations 6 155 $492.9 $69,101.9 $0.7 $21.0 3.5% 3.1% - 3.8%


4 196 $1,366.2 $67,961.3 $0.3 $33.2 0.9% 0.2% - 1.6%

Capitated Care/Fixed Payments 0 794 $0.0 $5,964,831.0 $0.0 $106.5 0.0% N/A

Crossover Claims 0 99 $0.0 $14,034.6 $0.0 $0.1 0.0% N/A


Hospice Services 0 5 $0.0 $1,053.0 $0.0 $0.5 0.0% N/A

ICF for Individuals with Intellectual Disabilities and Group Homes 0 49 $0.0 $720,662.9 $0.0 $2.4 0.0% N/A

Managed Care 0 2 $0.0 $92.2 $0.0 $9.6 0.0% N/A

Nursing Facility, Intermediate Care Facilities 0 8 $0.0 $30,084.3 $0.0 $0.2 0.0% N/A

Total 751 21,212 $414,465.2 $61,545,904.1 $94.9 $4,269.3 2.2% 1.9% - 2.5%


CHIP FFS Data Processing Payment Errors

Table T13. Summary of CHIP FFS Data Processing Overall Improper Payments


Error Type

Number of



Sample Paid Amount


Lower Confidence

Limit (millions)

Upper Confidence

Limit (millions)


1,673 $2,923,008.5 $2,923,004.5 $309.3 $273.7 $344.8



Pricing Error (DP5) 142 $37,509.1 $1,023,903.4 $3.0 $1.4 $4.7 Third-party Liability Error (DP4) 17 $761.7 $732.0 $2.5 -$1.1 $6.2


Data Entry Error (DP7) 42 $32,513.2 $38,372.0 $1.0 -$0.1 $2.0 FFS Payment for Managed Care Service (DP3) 3 $320.3 $320.3 $0.2 -$0.1 $0.6

Claim Filed Untimely (DP11) 3 $15,465.1 $15,465.1 $0.2 $0.0 $0.4 Data Processing Technical Deficiency (DTD) 329 $0.0 $2,825,993.8 $0.0 $0.0 $0.0

Total 2,888 $3,596,947.8 $61,545,904.1 $355.8 $318.5 $393.1 Note: Details do not always sum to the total due to rounding. Additionally, for error types with fewer than two claims per sample stratum, a confidence interval is not calculated.

Table T14. Summary of CHIP FFS Data Processing Overpayments

Error Type

Number of



Sample Paid Amount


Lower Confidence

Limit (millions)

Upper Confidence

Limit (millions)

Provider Information/Enrollment Error (DP10) 1,672 $2,922,993.5 $2,923,004.5 $309.2 $273.6 $344.8



Pricing Error (DP5) 66 $35,684.0 $1,023,903.4 $2.4 $0.9 $4.0


Data Entry Error (DP7) 42 $32,513.2 $38,372.0 $1.0 -$0.1 $2.0 Third-party Liability Error (DP4) 16 $732.0 $732.0 $0.9 -$0.8 $2.6


Error Type

Number of



Sample Paid Amount


Lower Confidence

Limit (millions)

Upper Confidence

Limit (millions)

FFS Payment for Managed Care Service (DP3) 3 $320.3 $320.3 $0.2 -$0.1 $0.6

Claim Filed Untimely (DP11) 3 $15,465.1 $15,465.1 $0.2 $0.0 $0.4 Data Processing Technical Deficiency (DTD) 329 $0.0 $2,825,993.8 $0.0 $0.0 $0.0

Total 2,808 $3,595,064.6 $61,545,904.1 $353.5 $316.4 $390.7 Note: Details do not always sum to the total due to rounding. Additionally, for error types with fewer than two claims per sample stratum, a confidence interval is not calculated.

Table T15. Summary of CHIP FFS Data Processing Underpayments

Error Type

Number of



Sample Paid Amount


Lower Confidence

Limit (millions)

Upper Confidence

Limit (millions)

Third-party Liability Error (DP4) 1 $29.7 $732.0 $1.6 N/A N/A

Pricing Error (DP5) 76 $1,825.1 $1,023,903.4 $0.6 $0.1 $1.2 Provider Information/Enrollment Error (DP10) 1 $15.0 $2,923,004.5 $0.1 N/A N/A

Administrative/Other (DP12) 1 $2.4 $2,454.9 $0.0 N/A N/A Non-covered Service/Recipient (DP2) 1 $10.9 $534,583.4 $0.0 N/A N/A

Duplicate Claim (DP1) 0 $0.0 $50,818.8 $0.0 N/A N/A

Data Entry Error (DP7) 0 $0.0 $38,372.0 $0.0 N/A N/A

Claim Filed Untimely (DP11) 0 $0.0 $15,465.1 $0.0 N/A N/A Data Processing Technical Deficiency (DTD) 0 $0.0 $2,825,993.8 $0.0 N/A N/A

FFS Payment for Managed Care Service (DP3) 0 $0.0 $320.3 $0.0 N/A N/A

Total 80 $1,883.2 $61,545,904.1 $2.3 -$0.9 $5.6 Note: Details do not always sum to the total due to rounding. Additionally, for error types with fewer than two claims per sample stratum, a confidence interval is not calculated.


Table T16. Specific Causes of Provider Information/Enrollment Error (DP10)


Cause of Error

Number of Sample

Improper Payments



Lower Confidence

Limit (millions)

Upper Confidence

Limit (millions)

Provider not screened using ACA risk based criteria 249 $420,619.4 $72.3 $56.5 $88.1

New provider was not enrolled using ACA risk-based criteria 366 $400,155.4 $65.6 $50.3 $81.0 Referring/Ordering/Prescribing provider NPI required, but not listed on claim 370 $229,615.2 $58.4 $48.6 $68.1

Referring/ordering provider not enrolled 115 $319,199.0 $30.9 $18.4 $43.4 Referring/ordering provider required but not listed on the claim 262 $142,105.4 $23.9 $12.3 $35.5

Attending or rendering provider required but not listed on institutional claim 98 $278,360.9 $21.3 $4.5 $38.2

Provider not enrolled in Medicaid/CHIP 91 $470,066.3 $18.5 $9.0 $28.0

Referring/Ordering/Prescribing provider not enrolled 43 $28,893.3 $6.0 $3.2 $8.8 Attending provider NPI required, but not submitted on institutional claim 30 $379,160.3 $4.7 $2.3 $7.2

Billing provider not enrolled 4 $1,913.5 $4.1 -$0.2 $8.4

Attending/rendering provider not enrolled 21 $245,158.6 $1.6 $0.5 $2.8

Required Prior authorization missing or not current for DOS 8 $4,041.6 $1.3 $0.3 $2.2

Required provider license was not current for DOS 7 $602.2 $0.3 $0.0 $0.7 Rendering provider NPI required, but not submitted on professional claim 3 $236.3 $0.1 -$0.1 $0.3

Provider license not current for DOS 4 $2,837.2 $0.1 -$0.1 $0.3

Other 1 $15.0 $0.1 N/A N/A

Prior authorization was required or not current for DOS 1 $28.8 $0.0 N/A N/A

Total 1,673 $2,923,008.5 $309.3 $273.7 $344.8 Note: Details do not always sum to the total due to rounding. Additionally, for error causes with fewer than two claims per sample stratum, a confidence interval is not calculated.

Table T17. Specific Sub-Causes of Provider Information/Enrollment Error (DP10)


Cause of Error Sub-Cause of Error Count of Errors

Provider not screened using ACA risk based criteria No required databases were checked prior to enrollment 172

Provider not screened using ACA risk based criteria Newly enrolled after 3/24/11 (or date allowed by SPA) 143

Provider not screened using ACA risk based criteria Social Security Death Master File (DMF) was not checked prior to enrollment 58

Provider not screened using ACA risk based criteria System for Award Management (SAM) or Excluded Parties List System (EPLS) not checked prior to enrollment 54

Provider not screened using ACA risk based criteria OIG LEIE database was not checked prior to enrollment 18

Provider not screened using ACA risk based criteria National Plan and Provider Enumeration System (NPPES) not checked prior to enrollment 16

Provider not screened using ACA risk based criteria On-site visit not conducted for moderate or high risk levels prior to enrollment 2

Note: It is possible for one claim to have multiple sub-causes for error. Therefore, one claim may be counted multiple times in this table.


Table T18. Specific Causes of Non-covered Service/Recipient Error (DP2)


Cause of Error

Number of Sample

Improper Payments



Lower Confidence

Limit (millions)

Upper Confidence

Limit (millions)


Other 464 $92,845.5 $13.4 $10.5 $16.3

Non-covered based on recipient’s benefit plan 3 $1,273.3 $0.8 -$0.3 $1.9

HCBS service not approved by recipient’s service plan 1 $21.3 $0.1 N/A N/A

Covered service incorrectly denied 1 $10.9 $0.0 N/A N/A


Data Processing Payment Errors: Administrative/Other Error (DP12)

Table T19. Specific Causes of Administrative/Other Error (DP12)

Cause of Error

Number of Sample

Improper Payments



Lower Confidence

Limit (millions)

Upper Confidence

Limit (millions)

State did not provide the documentation needed to complete the review 16 $1,450.6 $4.8 -$0.4 $10.0

State did not provide documentation needed to complete the review 3 $1,006.8 $0.9 -$0.4 $2.1


CHIP FFS Data Processing Errors by Service Type

Table T20. CHIP FFS Data Processing Error by Service Type


Category

Number of


Number of

Claims Sampled


Sample Paid Amount


Projected Paid

Amount (millions)

Improper Payment

Rate 95% CI

Prescribed Drugs 749 3,795 $754,938.5 $4,033,435.1 $98.2 $718.5 13.7% 11.2% - 16.2%

Dental and Other Oral Surgery Services 704 2,662 $99,161.7 $432,711.1 $74.7 $696.0 10.7% 8.7% - 12.8%

Psychiatric, Mental Health, and Behavioral Health Services 232 2,415 $890,636.1 $5,426,701.0 $39.5 $576.0 6.9% 5.3% - 8.4%

Inpatient and Outpatient Hospital 373 4,063 $1,739,377.9 $42,758,800.3 $38.6 $1,029.3 3.8% 3.0% - 4.5%

Habilitation and Waiver Programs, School Services 202 1,257 $31,389.4 $926,899.1 $30.8 $150.3 20.5% 16.2% - 24.8%

Physicians and Other Licensed Practitioner Services 141 2,008 $13,244.9 $431,047.3 $27.6 $428.9 6.4% 4.5% - 8.4%

Clinics 89 1,101 $11,793.6 $218,812.2 $17.4 $270.2 6.4% 3.0% - 9.9%


104 552 $5,747.6 $34,140.1 $12.5 $102.1 12.3% 8.4% - 16.1%


55 196 $10,286.7 $67,961.3 $5.0 $33.2 15.2% 10.8% - 19.5%

Personal Support Services 25 584 $16,733.7 $173,143.3 $4.7 $67.6 7.0% 5.8% - 8.1%

Laboratory, X-ray and Imaging Services 89 605 $2,968.0 $79,087.2 $2.3 $40.1 5.6% 2.9% - 8.4%

Home Health Services 63 317 $16,978.9 $163,306.2 $1.8 $16.7 11.0% 5.5% - 16.4%


Transportation and Accommodations 11 155 $1,189.0 $69,101.9 $0.5 $21.0 2.4% 0.8% - 3.9%


Category

Number of


Number of

Claims Sampled


Sample Paid Amount


Projected Paid

Amount(millions)

Improper Payment

Rate95% CI

Capitated Care/Fixed Payments 5 794 $701.1 $5,964,831.0 $0.3 $106.5 0.2% 0.1% - 0.4%

ICF for Individuals with Intellectual Disabilities and Group Homes 1 49 $337.9 $720,662.9 $0.1 $2.4 6.0% 5.0% - 7.0%

Crossover Claims 41 99 $1,269.5 $14,034.6 $0.0 $0.1 17.6% ( 0.9%) - 36.0%

Hospice Services 1 5 $148.8 $1,053.0 $0.0 $0.5 1.2% N/A

Managed Care 0 2 $0.0 $92.2 $0.0 $9.6 0.0% N/A

Nursing Facility, Intermediate Care Facilities 0 8 $0.0 $30,084.3 $0.0 $0.2 0.0% N/A

Total 2,888 21,212 $3,596,947.8 $61,545,904.1 $355.8 $4,269.3 8.3% 7.6% - 9.1%


CHIP Managed Care Component Improper Payment Rate

Table T21. CHIP Managed Care Data Processing Improper Payment Rates by State


State

Number of Sample

Improper Payments


Sample Paid Amount


National 245 $156,983.8 $2,063,104.1 1.0% 0.7% - 1.3%

Cycle 1 - ST1 76 $137,604.8 $433,066.3 30.6% 23.6% - 37.5%

Cycle 1 - ST2 36 $10,561.8 $50,714.0 13.9% 10.5% - 17.4%

Cycle 1 - ST3 19 $3,688.1 $42,047.3 7.6% 4.3% - 10.9%

Cycle 1 - ST4 4 $507.6 $35,573.4 1.8% ( 0.0%) - 3.5%

Cycle 3 - ST5 4 $1,104.3 $36,013.5 1.7% ( 0.1%) - 3.4%

Cycle 3 - ST6 3 $341.3 $25,170.3 1.3% ( 0.1%) - 2.7%

Cycle 3 - ST7 2 $338.5 $93,204.8 1.2% ( 0.5%) - 2.9%

Cycle 1 - ST8 3 $1,249.1 $55,862.0 1.1% ( 0.7%) - 2.9%

Cycle 3 - ST9 2 $189.6 $32,646.6 1.1% ( 0.4%) - 2.6%

Cycle 1 - ST10 9 $528.8 $56,505.2 0.9% ( 0.2%) - 2.0%

Cycle 2 - ST11 1 $92.2 $23,698.4 0.5% ( 0.4%) - 1.4%

Cycle 3 - ST12 72 $121.8 $29,596.3 0.4% ( 0.4%) - 1.3%

Cycle 1 - ST13 2 $21.1 $52,721.3 0.4% ( 0.4%) - 1.2%

Cycle 1 - ST14 1 $39.1 $33,971.6 0.4% ( 0.4%) - 1.1%

Cycle 2 - ST15 1 $148.8 $38,491.9 0.3% ( 0.3%) - 1.0%

Cycle 1 - ST16 1 $224.4 $44,738.5 0.3% ( 0.3%) - 1.0%

Cycle 3 - ST17 3 $82.4 $52,713.5 0.2% ( 0.2%) - 0.7%

Cycle 1 - ST18 1 $108.8 $17,157.6 0.2% ( 0.2%) - 0.6%

Cycle 2 - ST19 4 $31.5 $10,789.0 0.1% ( 0.1%) - 0.3%

Cycle 2 - ST20 0 $0.0 $23,327.6 0.0% 0.0% - 0.0%

Cycle 2 - ST21 0 $0.0 $26,481.2 0.0% 0.0% - 0.0%

Cycle 1 - ST22 0 $0.0 $59,362.3 0.0% 0.0% - 0.0%

Cycle 3 - ST23 0 $0.0 $102,333.5 0.0% 0.0% - 0.0%

Cycle 3 - ST24 0 $0.0 $27,437.1 0.0% 0.0% - 0.0%

Cycle 1 - ST25 0 $0.0 $7,452.6 0.0% 0.0% - 0.0%

Cycle 1 - ST26 0 $0.0 $130,038.7 0.0% 0.0% - 0.0%

Cycle 3 - ST27 0 $0.0 $19,095.8 0.0% 0.0% - 0.0%

Cycle 3 - ST28 0 $0.0 $39,137.7 0.0% 0.0% - 0.0%

Cycle 1 - ST29 0 $0.0 $36,376.2 0.0% 0.0% - 0.0%


State

Number of Sample

Improper Payments


Sample Paid Amount


Cycle 2 - ST30 0 $0.0 $49,891.9 0.0% 0.0% - 0.0%

Cycle 2 - ST31 1 $0.0 $37,656.4 0.0% 0.0% - 0.0%

Cycle 2 - ST32 0 $0.0 $21,721.5 0.0% 0.0% - 0.0%

Cycle 3 - ST33 0 $0.0 $62,370.0 0.0% 0.0% - 0.0%

Cycle 2 - ST34 0 $0.0 $54,294.3 0.0% 0.0% - 0.0%

Cycle 3 - ST35 0 $0.0 $42,378.6 0.0% 0.0% - 0.0%

Cycle 2 - ST36 0 $0.0 $76,738.8 0.0% 0.0% - 0.0%

Cycle 2 - ST37 0 $0.0 $31,447.7 0.0% 0.0% - 0.0%

Cycle 2 - ST38 0 $0.0 $29,119.7 0.0% 0.0% - 0.0%

Cycle 3 - ST39 0 $0.0 $21,761.2 0.0% 0.0% - 0.0% Note: Details do not always sum to the total due to rounding.

CHIP Managed Care Errors by Type of Error

Table T22. Summary of CHIP Managed Care Data Processing Projected Dollars by Type of Error

Error Type

Number of



Sample Paid

Amount


Lower Confidence

Limit (millions)

Upper Confidence

Limit (millions)


Managed Care Rate Cell Error (DP8) 47 $65,846.1 $69,096.6 $5.6 $2.5 $8.6



Managed Care Payment Error (DP9) 71 $0.7 $8,491.6 $0.0 $0.0 $0.0 Data Processing Technical Deficiency (DTD) 5 $0.0 $2,669.4 $0.0 $0.0 $0.0


CHIP Managed Care Data Processing Payment Errors

Table T23. Summary of CHIP Managed Care Data Processing Overpayments


Error Type

Number of



Sample Paid

Amount


Lower Confidence

Limit (millions)

Upper Confidence

Limit (millions)


Managed Care Rate Cell Error (DP8) 43 $65,825.0 $69,096.6 $5.6 $2.5 $8.6


Duplicate Claim (DP1) 3 $5,860.4 $5,860.4 $0.3 -$0.1 $0.6 Data Processing Technical Deficiency (DTD) 5 $0.0 $2,669.4 $0.0 $0.0 $0.0

Managed Care Payment Error (DP9) 0 $0.0 $8,491.6 $0.0 N/A N/A


Table T24. Summary of CHIP Managed Care Data Processing Underpayments

Error Type

Number of



Sample Paid

Amount


Lower Confidence

Limit (millions)

Upper Confidence

Limit (millions)

Managed Care Rate Cell Error (DP8) 4 $21.1 $69,096.6 $0.0 $0.0 $0.0

Managed Care Payment Error (DP9) 71 $0.7 $8,491.6 $0.0 $0.0 $0.0


Third-party Liability Error (DP4) 0 $0.0 $229.2 $0.0 N/A N/A

Data Processing Technical Deficiency (DTD) 0 $0.0 $2,669.4 $0.0 N/A N/A

Total 75 $21.8 $2,063,104.1 $0.0 $0.0 $0.0 Note: Details do not always sum to the total due to rounding. Additionally, for error types with fewer than two claims per sample stratum, a confidence interval is not calculated.


Table T25. Specific Causes of Non-covered Service/Recipient Error (DP2)


Cause of Error

Number of Sample

Improper Payments



Lower Confidence

Limit (millions)

Upper Confidence

Limit (millions)



Data Processing Payment Errors: Managed Care Rate Cell Error (DP8)

Table T26. Specific Causes of Managed Care Rate Cell Error (DP8)

Cause of Error

Number of Sample

Improper Payments



Lower Confidence

Limit (millions)

Upper Confidence

Limit (millions)

Incorrect rate cell used for DOS 37 $53,923.8 $3.6 $2.2 $4.9

Recipient moved into a different MCO area 1 $148.8 $1.4 N/A N/A

Other 7 $11,768.8 $0.6 $0.1 $1.1

Incorrect rate cell used for aid category 2 $4.7 $0.0 $0.0 $0.1


Data Processing Payment Errors: Third-party Liability Error (DP4)

Table T27. Specific Causes of Third-party Liability Error (DP4)


Cause of Error

Number of Sample

Improper Payments



Lower Confidence

Limit (millions)

Upper Confidence

Limit (millions)

Payment should have been denied pending payment by TPL 1 $140.0 $1.3 N/A N/A

Other 1 $89.2 $0.4 N/A N/A

Total 2 $229.2 $1.7 -$1.0 $4.5 Note: Details do not always sum to the total due to rounding. Additionally, for error causes with fewer than two claims per sample stratum, a confidence interval is not calculated.

Appendix 5: Medicaid and CHIP Review Methodology

Medicaid and CHIP FFS claims were subjected to data processing review and, if applicable, medical review. Medicaid and CHIP managed care payments were subjected only to data processing review. If an error was identified during medical review or data processing review, states were given the opportunity to participate in difference resolution and appeal to CMS. Medicaid and CHIP eligibility cases were reviewed by states.

Medical Review Methodology

From a state’s quarterly sample selection, detailed information on each sampled claim was requested from the state and copies of the relevant medical records were requested from the providers. The medical records were used to perform medical reviews on the claims to validate whether the claim was paid correctly. Each claim was assessed to determine the following.

Adherence to federal regulations, state guidelines, and policies related to the service type; Completeness of medical record documentation to substantiate the claim; Medical necessity of the service provided; Validation that the service was provided as ordered and billed; and Claim was correctly coded.

A medical review error is a payment error that is determined from a review of the medical documentation submitted, the relevant state and federal policies, and a comparison to the information presented on the claim. The medical reviews consisted of reviewing sampled FFS claims for the errors listed in Table Appx.1.

Table Appx.1. Medical Review Error Codes


Error Code Error Definition

MR1 No Documentation The provider failed to respond to requests for the medical records. MR2 Incomplete

Documentation There is not enough documentation to support the billed service.

MR3 Procedure Coding Error The provider performed a procedure, but billed using an incorrect procedure code.

MR4 Diagnosis Coding Error The provider billed using an incorrect diagnosis code and/or DRG. MR5 Unbundling The provider billed for the separate components of a procedure code

when only one inclusive procedure code should have been billed. MR6 Number of Unit(s) Error The provider billed for an incorrect number of unit(s) for a particular

service provided. MR7 Medically Unnecessary

Service The provider billed for a service determined to have been medically unnecessary based upon the information regarding the patient’s condition in the medical record.

MR8 Policy Violation Either the provider billed and was paid for a service that was not in agreement with state policy or the provider billed and was not paid for a service that, according to state policy, should have been paid.



MR9 Inadequate Documentation

The required documentation is present, but the documentation is inadequately completed to verify that the services were provided in accordance with policy or regulation.

MR10 Administrative/Other A payment error was discovered during a medical review, but it did not fit into one of the above error categories.

MTD Medical Technical Deficiency

Medical review determined a deficiency that did not result in a payment error.

Data Processing Review Methodology

Data processing reviews were also conducted to validate that each sampled payment was processed correctly based on information found in the state’s claims processing system when it was adjudicated compared with the following.

State specific policies and fee schedules in effect at the time of payment; Applicable federal regulations; Beneficiary enrollment; and Provider participation in the Medicaid program.

A data processing error is a payment error resulting in an overpayment or underpayment that could be avoided through the state’s Medicaid Management Information System (MMIS) or other payment system. Claims not processed through a state’s MMIS were subject to validation through a paper audit trail, state summary or other proof of payment. The data processing reviews consisted of reviewing the sampled claims for the errors listed in Table Appx.2.

Table Appx.2. Data Processing Error Codes


DP1 Duplicate Claim An exact duplicate of the sampling unit was paid. DP2 Non-covered Service/Recipient State policies indicate that the service is not payable by

Medicaid/CHIP under the state plan or for the coverage category under which the person is eligible.

DP3 FFS Payment for a Managed Care Service

The recipient is enrolled in a managed care plan and the managed care plan should have covered the service rather than being paid under FFS.

DP4 Third-party Liability Error A third-party insurer is liable for all or part of the payment. DP5 Pricing Error Payment for the service does not correspond with the pricing

schedule for that service. DP6 System Logic Edit Error A system edit was not in place based on policy or a system edit was

in place, but was not working correctly and the sampling unit was paid (e.g., incompatibility between gender and procedure or ineligible recipient or provider).

DP7 Data Entry Error Clerical error in the data entry of the sampling unit.



DP8 Managed Care Rate Cell Error The recipient was enrolled in managed care and payment was made, but for the wrong rate cell

DP9 Managed Care Payment Error The recipient was enrolled in managed care, but was assigned the wrong payment amount.

DP10 Provider Information/Enrollment Error

The provider was not enrolled in Medicaid or CHIP according to federal regulations and state policy or required provider information was missing from the claim.

DP11 Claim Filed Untimely The claim was not filed within timely filing requirements for the date of service in accordance with federal regulations and state guidelines.

DP12 Administrative/Other A payment error was discovered during data processing review, but the error was not a DP1 – DP11 error.

DTD Data Processing Technical Deficiency

A deficiency was found during data processing review that did not result in a payment error.

Difference Resolution

If an error was identified that affected payment, the state was notified and given an opportunity to review the documentation associated with the payment and dispute the error finding. If the state requested a difference resolution, then an independent difference resolution review was performed to consider the state’s information and to make a final determination. If the state disagreed with the determination, then the state could then appeal the error finding to CMS.

Errors that were not challenged by the states or upheld following the difference resolution and appeal process were included in the improper payment rate calculation. If a payment error was found in both the data processing review and medical review for a specific claim, the total error amount reported was adjusted to not exceed the total paid amount for the claim, unless the underpayment amount exceeded the original claim amount, such as in the case of zero-paid claims.

Eligibility Review Methodology

While every state has operated both Medicaid and CHIP for many years, the passage of the Patient Protection and Affordable Care Act of 2010 (ACA) significantly affected each program by adding new requirements, expanding eligibility, and offering additional federal funding to states for eligibility system updates and development. States continue to plan and implement major changes to their Medicaid program and CHIP to comply with the ACA and to improve accountability and quality of care.

Accordingly, new PERM eligibility measurement regulations need to be promulgated to reflect the required changes states are making to their eligibility processes and systems. Therefore, for Fiscal Year (FY) 2014 – 2017 (Cycles 3, 1, 2, and 3 respectively), which will be reported in 2015 – 2018, CMS is suspending the formal eligibility component of PERM. While CMS develops the new eligibility review methodology, the eligibility improper payment rates from the most recent cycles

prior to 2016 are used as a proxy in calculating the overall Medicaid and CHIP improper payment rate calculation, along with data from the PERM FFS and managed care payment reviews that continue as normal during this period. The proxy rate will only have an impact on the national-level improper payment rates, as all state-specific rates will be comprised of only the PERM FFS and managed care components until eligibility review is resumed for reporting in 2019. In lieu of the suspended PERM eligibility review, CMS has required states to conduct Medicaid and CHIP Eligibility Review Pilots to continue to assess and drive down eligibility-related errors.

Claim Categories

Claim categories are listed in Table Appx.3.

Table Appx.3. Claim Categories


Claim Category

Code Claim Category Description

1 Inpatient Hospital Services 2 Psychiatric, Mental Health, and Behavioral Health Services 3 Nursing Facility, Intermediate Care Facilities 4 ICF for Individuals with Intellectual Disabilities and Group Homes 5 Clinics 6 Physicians and Other Licensed Practitioner Services 7 Dental and Other Oral Surgery Services 8 Prescribed Drugs 9 Home Health Services 10 Personal Support Services 11 Hospice Services

12 Occupational, Respiratory Therapies; Speech Language Pathology, Audiology; Ophthalmology, Optometry, and Optical Services & Rehabilitation Services, Necessary Supplies & Equipment

13 Habilitation and Waiver Programs, School Services 14 Laboratory, X-ray and Imaging Services 15 Outpatient Hospital Services

16 Durable Medical Equipment (DME) and supplies, Prosthetic/Orthopedic devices, and Environmental Modifications

17 Transportation and Accommodations 18 Denied Claims 19 Crossover Claims 30 Capitated Care/Fixed Payments 50 Managed Care 99 Unknown

Appendix 6: Statistical Sampling and Formulae

The sampling process for PERM follows a stratified two-stage design. First, all 50 states plus the District of Columbia were stratified into three strata of 17 states each based on historical total Medicaid FFS expenditures. The top strata consisting of the 17 states with the greatest expenditures were further divided into two strata: a nine state stratum of the largest expenditure states and a stratum with the remaining eight states. The states from each state stratum were selected by random sampling. States were selected to be reviewed on a three year rotation such that 17 different states would be reviewed each year and all states would be reviewed over a three year time span. This sampling of states constitutes the first stage of the sample. Within each sampled state the universe of claims was then further stratified. The sampled claims were subjected to medical and data processing reviews, as appropriate, to identify proper and improper payments. As a result of the reviews, state level improper payment rates were calculated.

The state level improper payment rate is estimated by this equation as:

In the equation, is the estimated improper payment rate for state i; is the estimated dollars in

error projected for state i and is the estimated total payments for state i. Then,

and

In these equations, is the number of items in the universe for state i in strata j and is the number of items in the sample for state i in stratum j. The ratio of items in the universe to items in the sample (i.e., the weight for that stratum, quarter, and state) is the inverse of the sampling frequency. Dollars in error in the sample for stratum j and state i, denoted , is weighted by the inverse of the sampling frequency to estimate dollars in error in the universe for that stratum. For example, if there are 10,000 items in the universe in stratum j, and the sample size in j is 200 items, the weight for the dollars in error in the stratum j sample is 50 (10,000/200). The estimated total dollars in error are then added across each of the J strata to obtain total dollars in error for the universe. Total payments are estimated in the same way, where is the total payments in the sample in stratum j for state i.


Cycle-Specific Statistics

To go from the improper payment rates for individual states to a cycle-specific improper payment rate, each state is first benchmarked to its reported payments. Then, the error and payment amounts are summed across the cycle states and divided to calculate the cycle rate. This ensures that the states’ payment and error amounts will be proportional to the size of the state. In other words, a larger state would contribute more to the cycle-specific improper payment rate than a smaller state.

The formula for the 17 state cycle improper payment rate is as follows:

where:

= 17 state cycle improper payment rate.

= total payments for state i.

= estimated improper payment rate for state i.

u = total number of states sampled in the cycle (17 for Medicaid and CHIP).

= total universe payments for the 17 states in the cycle.

Rolling National Improper Payment Rates The rolling national improper payment rates are calculated using the same approach as for the 17 state cycle improper payment rate. In 2016, the rolling national improper payment rates for Medicaid and CHIP are calculated from data sampled in 2014, 2015, and 2016. Each of the rolling improper payment rates (i.e., total program, FFS, MC, and Eligibility) is calculated with the same methodology.

Data from 2014, 2015, and 2016 are combined and weighted by each state’s expenditures from the year they were sampled. The formula for the rolling improper payment rate is as follows:

where:

= rolling improper payment rate.

= total payments for state i.


= estimated improper payment rate for state i. s = total number of states sampled (51 for Medicaid and CHIP).

= total universe payment.

Combining Claims Review Improper Payment Rates across Program Components

Combining the claims review improper payment rates, (i.e., combining the FFS and managed care improper payment rates for Medicaid) is relatively straightforward because the population payments are known from federal financial management reports. Note that CMS does not utilize true population payments in calculating state rates for each program component. The reason for this is two-fold. First, the combined ratio estimator used allows for correction in possible bias if the sampled average payment amount differs from the universe average payment amount. However, if CMS utilized a combined ratio estimator to combine the program components at the state level, one program component that realized high sample average payment amount compared to the universe average would have too much influence in projections. For this reason, combining program component rates using the shares of expenditures as weights reduces the variance in the estimates from this source. Furthermore, following this method allows the same method for combining program component claims review rates at the state, cycle-specific, and national level.

The following equations utilize the estimated state, cycle-specific, or national improper payment rates calculated in the previous three sections.

Let the overall claims review improper payment rate for Medicaid/CHIP be defined as:

where:

.

In this equation, is the estimated improper payment rate for FFS, managed care or combined (C), and t represents total payments for FFS, managed care, or the total, depending upon the subscript.

Improper Payment Rate Formula

Sampled claims or cases are subject to reviews, and an improper payment rate is calculated based on those reviews. The improper payment rate is an estimate of the proportion of improper payments made in Medicaid/CHIP to the total payments made.


The national rolling improper payment rate was computed using a separate ratio estimator, which combines the improper payment rates from each state using the federally reported Medicaid/CHIP expenditures for those states. This method projects the improper payments and total payments using the sampling frequency of units from the state. State, cycle-specific, and national rolling rates are calculated for each program component—FFS, managed care and eligibility—and are also combined into an overall rate, representing the total improper payment rates for the program at the state, cycle-specific, and national levels.

For the calculation of state level statistics, the improper payment rate estimator is a combined ratio estimator. The numerator consists of estimated dollars in error in the universe, and the denominator is estimated total payments, both projected from the sample on the basis of the sampling weights (i.e., the inverses of the sampling frequencies). The sample is drawn from a universe that is divided into the strata relevant to that universe, as described above. The sample dollars in error and sample payments are weighted by the inverse of the strata sampling frequencies to estimate universe values. The sampling frequencies, which are the rates at which items were sampled, vary by stratum.

To calculate the cycle-specific or national rolling improper payment rate based on the individual state improper payment rates, each state is first benchmarked to its reported payments. Then, the error and payment amounts are summed across the cycle states or all 51 states and divided in order to calculate the improper payment rate.

Eligibility Improper Payment Rate Formula

From 2015 – 2018, eligibility reviews are on hold and eligibility results from the most recent cycles are used as a proxy in the overall improper payment rate calculation while CMS develops a new eligibility review methodology. The eligibility rates used as a proxy in the 2016 improper payment rate were the same eligibility rates from states participating in the 2012, 2013, and 2014 PERM cycle measurements.

Combining the Claims and Eligibility Improper Payment Rates

After combining the FFS and managed care components into one overall claims improper payment rate for Medicaid at the state, cycle-specific, and national rolling levels, these combined claims and managed care improper payment rates are then combined with the respective eligibility improper payment rates. The combining of the claims improper payment rate and the eligibility improper payment rate is referred to as the combined improper payment rate. The following procedure is followed at the state, cycle-specific, and national rolling levels. That is, the claims improper payment rates are combined at the state level and combined in separate instances at the cycle-specific level and then at the national level. The estimated combined improper payment rate is given by:

where:


denotes the estimated Total, or Combined Improper Payment Rate.

denotes the estimated Claims Improper Payment Rate.

denotes the estimated Eligibility Improper Payment Rate.


Date post:	01-Aug-2020
Category:	Documents
Upload:	others
View:	1 times
Download:	0 times

November 2016 PERM Report Appendix - CMS · November 2016 . Appendix 1: Medicaid Trending for...

Documents