Universe and Medical Record
Payment Error Rate Measurement Support

Medicaid Disproportionate Share Hospital (DSH)

January 2019

To comply with the Improper Payments Information Act of 2002, which has since been supplemented by the Improper Payments Elimination and Recovery Act, the Centers for Medicare & Medicaid Services (CMS) in fiscal year 2006 implemented the payment error rate measurement (PERM) methodology.

PERM includes three scopes of review: data processing, medical review, and eligibility review, and each of these has a designated national CMS contractor for specific areas within the scope. The Statistical Contractor (SC) validates a state’s Medicaid and CHIP claim universe and sampling claims for testing. The Review Contractor (RC) conducts data processing and medical reviews. The Eligibility Review Contractor completes eligibility reviews.

The Office of Management and Budget identified the Medicaid program and Children’s Health Insurance Program (CHIP) to be at risk for significant improper payments. 

While payment integrity is always essential, the complex and ever-changing landscape of drivers, issues, and stakeholders surrounding these program reviews makes it difficult to ensure integrity. Every state has its own methods for administration and oversight of its Medicaid and CHIP programs. And because states have various responsibilities throughout the PERM review cycle, prioritizing their efforts can be challenging.

How We Can Help

With more than four decades of experience supporting our state government health care clients, Myers and Stauffer is well qualified to assume some of these burdens so that your team can dedicate time and redirect resources to the more difficult and emergent issues affecting Medicaid and CHIP programs.

Targeted Services for Critical Phases

PERM Planning Activities Leadership

● Participation in calls with CMS.
● Provision of general PERM training, including staff to educate providers and others within Medicaid and CHIP about the PERM process.
● Completion of contractor questionnaires required by the SC and RC.
● Assistance to the RC with obtaining relevant policies and procedures.

SC Universe Development

● Support of universe development and management, as well assistance with the outreach and management of the medical record review/data processing processes.
● Support from data analysts experienced in preparation of claims universe and detailed data extracts that satisfy requirements mandated by CMS and the SC.
● Performance of quality assurance steps and reconciliation of aggregate payments to the CMS-64 quarterly reports.

Medical Record Review Coordination

● Collaboration with RC to obtain medical records and documents for PERM review.
● Coordination with state subject matter experts (SMEs) to develop responses to different error resolutions. Appeals to CMS for errors upheld by the RC.
● Preparation of referrals for suspected fraud, waste, and abuse to the Surveillance and Utilization Review Subsystem.
● Assistance with provider enrollment errors.

Corrective Action Plan (CAP) Support

● Assistance with preparing the CAPs for cited medical review errors to ensure appropriate responses.
● Assistance with responses to comments on the CAP from CMS.