Comprehensive Error Rate Testing (CERT)
Call Center Problem Tickets
The CERT Documentation Contractor (CDC) Customer Service Representatives (CSRs) in the CERT call center contact hundreds of providers each day to verify provider addresses and phone numbers. These calls are also an opportunity to inform providers that CERT will be sending request letters for medical records on specific patients. A recent analysis by the CDC of these calls shows providers telling the CSRs “that is not our patient” or “wrong date of service” in 76% of the requests. In order to clarify the accuracy of this percentage, the CDC had one of their problem Resolution Office (PRO) specialists do a little deeper research into sample calls. Approximately 30 “problem” calls in the “not our patient” category and 20 calls from a related problem category – “wrong date of service”. Each problem was examined by comparing information concerning the medical request in the database with information from each provider and with the original claim as filed with the Affiliated Contractor (AC). Of the samples examined, only one medical record request was inaccurate with an incorrect provider number.
Reasons for providers indicating “not our patient” and/or “wrong date of service” include the following:
- Time Gaps: patient records not yet available for recent patient visits, records not yet filed.
- Provider Error: person taking call from CSR provided incorrect information.
- Multiple facilities and multiple doctors: providers often have multiple locations with a variety of doctors treating patients. There might be a correct provider phone number but that number may not be the number to the person who has access to the medical records.
- Patient was seen in a hospital setting. Doctor’s office submits Medicare claims for the patient. Doctor’s office staff does not have access to the medical records because the records are housed at the hospital.
This limited study of the problems will allow us all to better understand where and how mistakes and omissions occur.
