In Part 1, we reviewed disposition codes 01, 02, 03, 50 and 51. In Part 2, we will focus on the SP disposition code, which indicates an error within the claim submission. Why are these particular codes important to review? They are a performance indicator for either an RRE’s self-reporting processes or reporting agent. The COBC will reject an entire claim file if it finds that 20% of the records are in error, and while the COBC has been lenient on releasing submissions, there are indications that this will get tighter as we move forward.
It is important to note, however, that an SP disposition code alone is not enough to make a complete diagnosis for problems with the claim. An SP disposition code will be accompanied with one or more (up to 10) error codes against the claim. CMS will only return 10 errors with the claim, and feedback for any errors received over 10 will not be provided. RREs should pay close attention to the percentage of claims that are returned in its quarterly submission file with an SP disposition code. There are two areas for concern: the number of claims that have an SP code, and the number of errors on each claim. Let us examine why both of these statistics are so important.
If your quarterly file has SP codes, what is the percentage against the total claims? For example, if 1000 claims were reported and 40 of them are rejected with an SP code, there would be a 4% error rate. Is that an acceptable error rate? One would argue that it is probably not unless there is a reasonable explanation as further discussed below. We say “probably not” because as this is Q3 of 2011, we have over two dozen reporting windows behind us. If you or your reporting agent do not have the guidelines down at this point, when will you? If your reporting agent is blaming you, the RRE, in this process, perhaps asking your reporting agent what value they are bringing to the table is a question that should be raised. The reporting agent’s primary goal should be helping you achieve the highest compliance level possible, which means the least number of SP codes.
As mentioned earlier, knowing how many claims were returned with an SP disposition code is the first part of the puzzle. Next, identify how many claims had multiple errors and whether any were returned with enough errors to fill all 10 possible error slots. If the answer here is “yes,” then you may want to re-evaluate your process or express concern to your reporting agent for these errors. If CMS has filled all available slots with errors, then your reporting agent clearly has issues with their ability to validate the data or they may just be sending data without a concern for what is present in the file. Further, if there are 10 errors on a claim, there are probably more that just couldn’t be returned, for lack of slots in the response file. When do you think you will know about those errors? Unfortunately, probably not until the claim is rejected by CMS next quarter!
Not all SP errors are negative. On some occasions there may be issues that can’t be avoided by your reporting agent. An example would be the SP31 disposition and error code combination. Once again, we will default to the user guide’s description of why this error might occur:
The COBC usually receives entitlement information for individuals in advance of their Medicare entitlement date. If an individual is to become entitled to Medicare on 7/1/2010 and a query record is processed on 6/10/2010 the query response record disposition code will most likely be ‘01’ since the record will be matched to a Medicare beneficiary, albeit a future one. If you then send a Claim Input File Detail Record for this person and it is processed prior to 7/1/2010, it will be rejected with an SP disposition code and the SP31 error. No correction on the part of an RRE is necessary for an SP31 error. RREs only need to resubmit the record on their next quarterly Claim Input File and it will be processed and returned with the appropriate disposition.”
Pay close attention to the fact that no corrective measure can be taken and the reporting agent just needs to resubmit the record the following quarter. The SP31 error could arguably not even be classified as an error. You might think it similar enough to compare to a disposition 50 or 51 type of scenario, but CMS likely has it as an error so that it can easily be passed back to them the following quarter. For these reasons, the SP31 could be taken out of the error measurement in your results discussion with your reporting agent.
The error rate your reporting agent experiences can then be broken down a bit further if you take the total number of SP percentage claims and reduce it by the percentage of SP31 claims. That number is going to start to look like a comparable number and from there you can gauge the performance of the reporting agent with which you are dealing. Can your agent provide this number to you? If another reporting agent is courting you, will they provide it as well? If you are concerned with compliance and performance levels, don’t be afraid to ask these questions—but be specific. As with many measurements, you might not be seeing a complete picture unless you are armed with the correct knowledge and know what to ask.
Back in June, PMSI released an acceptance rate by CMS of 95%. It is interesting to note that a 95% acceptance rate should not be interpreted as a 5% error rate. Making this assumption means not taking into account the full range of possible responses from CMS. There is a gap between the acceptance rate and the error rate that includes the possibilities of disposition codes 50 and 51 along with non-correctable errors like SP31. This reinforces the need to be well informed so you can understand your results and ask appropriate questions.
Once you have an analysis of your reporting results and know the true error percentage your reporting agent is obtaining for your claim set, the focus should turn to how they are resolved. What efforts does your agent put forth to resolve the errors? If your reporting agent does not review the feedback being returned from CMS, they should be. This feedback will likely indicate two areas of concern: validations that need to be reviewed by your agent and data issues within your claims that you should examine. Maybe you have an agent that isn’t concerned about this type of analysis and leaves it all on your plate, with the theory that they only pass through what you provided to them. If that’s the case, your agent is missing a vital opportunity to strengthen their system to provide the highest level of compliance possible. And if that isn’t their goal—to help you obtain the highest level of compliance with CMS guidelines—then your best bet is to find someone who is willing to go the extra mile.