Success Metrics > Benchmarks

Exceeding standards and the highest benchmarks requires every indicator be on point.

 

Palmetto GBA's performance across all contract metrics in 2021.

 

 Palmetto GBA was rated Exceptional or Very Good by CMS on 29 out of 38 assessed elements.

 

Medicare Prescription Drug, Improvement, and Modernization Act

Section 912 Audit Improvements

The Medicare Prescription Drug, Improvement, and Modernization Act (MMA) of 2003 established information security requirements for Medicare Fiscal Intermediaries, carriers and their data centers. MMA Section 912 requires each of these contractors have its information security program evaluated annually by an independent entity.

Within Section 912, there are 10 Federal Information Security Management Act (FISMA) control families referenced. The annual risk assessment evaluates these complex requirements and determines if a contractor’s current security controls are sufficient. If inadequacies are found, they’re categorized as high, medium or low risk.

Zero

high findings from current audit

Our recent focus on improvement in this area paid off significantly last year. Our current audit finished with ZERO high findings –a first for Palmetto GBA. Additionally, we had only two medium and eight low findings, keeping us below other contractor averages and setting us on a road for continued improvement and success.

 
Medicare Integrity Program Results
 

Jurisdiction M A/B Medicare Administrative Contractor

Jurisdiction J A/B Medicare Administrative Contractor

Railroad Board Specialty Medicare Administrative Contractor

Benefit Integrity

 		N/A N/A $1,622,507

Medicare Secondary Payer

 		$587,864,543 $537,578,716 $4,898,154

Medical Review

 		$283,272,233 $255,266,935 $8,787,042

Medical Review Ambulance Prior Authorization

 		$1,597,870 N/A N/A

Medical Review Outpatient Department Prior Authorization

 		$3,139,121 $1,091,212 N/A

Total

 $875,873,767 $793,936,863 $15,307,703

Continued Savings for the Medicare Trust Fund

Advanced Communication Engine (ACE) Contributions

Using the Advanced Communication Engine (ACE) tool, Palmetto GBA continued to provide savings to the Medicare Trust Fund last year, while also offering an enhanced claims processing system for our Part B providers. ACE identifies problematic or “certain to deny” claims prior to adjudication, alerts providers of errors or potential claims issues, and uses timely, SMART messaging to deliver information on how to fix the error. The tool increases claims processing accuracy, reduces cycle times associated with claim resubmissions, and provides an enhanced customer experience.

In 2021, we implemented 34 new SMART edits to ACE, eight of which are information-driven and supply additional alerts and awareness of various Medicare program requirements to providers.

The tool increases claims processing accuracy, reduces cycle times associated with claim resubmissions, and provides an enhanced customer experience.

2021 ACE Impacts

  • 2.2+ million claims denied

  • 61,723 claims denied due to new SMART edits

  • 83.6% of denied claims resubmitted

  • $85.1 million reduction in charges based on denied, resubmitted claims using ACE-issued education

  • 421,685 additional claims denied but not resubmitted before year end