Provider Error Rate

3.7.1.1 - Provider Error Rate (Rev. 738; Issued: 08-18-17; Effective Date: 09-19-17; Implementation Date: 09-19- 17) This section applies to MACs. If the MAC identifies a provider-specific problem, the provider error rate is an important consideration in deciding how to address the problem. For instance, a provider with a low error rate with no history of patterns of errors may require a fairly minor corrective action plan such as education with recoupment of overpayment. Other factors such as the total dollar value of the problem and the past history of the provider also deserve consideration. The MAC assesses the nature of the problem as minor, moderate or major and uses available tools such as data analysis and evaluation of other information to validate the problem. A. Provider Error Rate Formula The MACs shall include claims denied due to no response to ADRs when calculating the provider error rate. The MACs shall use the following formula for prepayment review to calculate the provider’s service specific error rate: Total Dollar amount of allowable** charges for services billed in error as determined by MR*** Total Dollar amount of allowable** charges for services subject to a medical review documentation request For postpayment review, the MACs shall use the following formula to calculate the provider’s service specific error rate: Total Dollar amount of services paid in error as determined by MR*** Total Dollar amount of services subject to a medical review documentation request **If allowable charges are not available, submitted charges may be used until system changes are made. ***Net out (subtract) the dollar amount of charges under billed