Improper Payments Measurement Programs

Background

The Payment Integrity Information Act of 2019 (PIIA) (Public Law No. 116-117) requires government agencies to identify, report, and reduce improper payments in the government's programs and activities. The implementation guidance in Appendix C of the Office of Management and Budget (OMB) Circular No. A-123 requires executive branch agency heads to review their programs and activities annually and identify those that may be susceptible to significant improper payments. For programs deemed susceptible to significant improper payments, CMS must obtain a statistically valid estimate of the annual amount of improper payments, implement a plan to reduce improper payments, and report annually in the Agency Financial Report (AFR).

In compliance with the PIIA, the Department of Health and Human Services (HHS), Centers for Medicare & Medicaid Services has implemented a systematic plan for identifying, measuring, and reporting erroneous payments.

Improper Payments Measurement Programs

Comprehensive Error Rate Testing (CERT)

The CERT program measures the improper payment rate in the Medicare Fee-for -Service (FFS) program. The CERT program reviews a statistically valid stratified random sample of all Medicare FFS claims to determine if they were paid properly under Medicare coverage, coding, and payment rules.

You can find more information on the CERT program here.

Medicare Part C Improper Payment Measurement (Part C  IPM)

The Part C IPM activities verify that diagnosis codes submitted for payment by an MA organization are supported by medical record documentation for an enrollee. Payment validation ensures the accuracy of Medicare Part C program payments, and protects the Medicare Trust Fund.

You can find more information on the Part C IPM program here.

Medicare Part D Improper Payment Measurement (Part D  IPM)

The Part D IPM measures error in payments due to invalid and/or inaccurate PDE records, which results in adjustments to beneficiaries’ benefit phases and reinsurance subsidy payments. Payment validation ensures the accuracy of Medicare Part D program payments, and protects the Medicare Trust Fund.

You can find more information on the Part D IPM program here.

Payment Error Rate Measurement Program (PERM)

The PERM program measures improper payments in Medicaid and Children's Health Insurance Program (CHIP) and produces improper payment rates for each program. The improper payment rates are based on reviews of the Fee-For-Service (FFS), managed care, and eligibility components of Medicaid and CHIP in the Reporting Year under review.

You can find more information on the PERM program here.

Exchange Improper Payment Measurement (EIPM)

The EIPM program measures improper payments for Advance payments of the Premium Tax Credit (APTC), as administered by the American Health Benefit Exchanges. The EIPM program is currently under development and more information will be added at a later date.