Palmetto GBA Partnering with Providers to Get it Right the First Time

Imagine not having to appeal claim denials because the initial submission was correct. How much time, effort and resources would that save you? Palmetto GBA and the provider community can partner to ensure claims are paid correctly the first time. As a Medicare contractor for the Centers for Medicare & Medicaid Services (CMS), Palmetto GBA is tasked with preventing claims payment errors. At Palmetto GBA, the Medical Review (MR) staff analyzes and reviews claims (on a pre- or post-payment basis) to ensure documentation for claims submitted to Medicare meet all CMS guidelines, rules and regulations.

Palmetto GBA’s goal is to work with providers to identify and communicate errors that are causing denials and generating appeals. This information comes from several sources including the Comprehensive Error Rate Testing (CERT) contractor and Palmetto GBA’s own review experience. The CERT contractor’s job is to estimate the error rate by sampling claims from every AB MAC Jurisdiction and then calculating both a jurisdiction-specific error rate and a national error rate. Palmetto GBA’s job is to partner with providers to understand where and why the errors occur and then take action to reduce or if possible eliminate the errors.

Errors may occur at different steps of the Health Information Supply Chain (HISC) and for a variety of reasons.

The CERT contractor is responsible for establishing the paid claims error rate for all MAC jurisdictions and the nation. This national paid claims error rate is used to evaluate each jurisdiction and is also monitored and tracked by Congress. It is imperative for providers and Palmetto GBA to work together to reduce our jurisdiction’s error rate.

The combined goal of MR and POE is to proactively share educational materials and follow-up on error prone providers. These steps ensure that both Palmetto GBA and providers collaborate so that all parties are responsible for reducing the CERT error rate. This includes CERT letters, CERT Tech Stop calls and notification of repetitive incorrect billing issues that increase the CERT error rate.

Once errors are identified, information is used to develop education and training for individual providers and the provider community as a whole. Palmetto GBA’s Provider Outreach and Education staff provides education through a variety of resources which include:   

• Provider education letters
• Teleconferences
• Webcasts (live and pre-recorded in the webcast library)
• Articles and Frequently Asked Questions (FAQs) posted on the website
• Face-to-face workshops

The education should be specific enough to help you understand where in the HISC your errors are occurring and help you then answer the questions "Why are they occurring?" and "How can I prevent them?" Following this procedure will permit us to improve our processes and eliminate wasted effort.

Together, Palmetto GBA and the provider community can partner to ensure claims are paid correctly the first time.