The CMS implemented the CERT program to measure improper payments in the Medicare FFS program.
CERT selects a stratified random sample of approximately 50,000 claims submitted to Part A/B MACs and DME MACs during each reporting period. This sample size allows CMS to calculate a national improper payment rate and contractor and service-specific improper payment rates.
It is important to note that the improper payment rate is not a “fraud rate,” but is a measurement of payments that did not meet Medicare requirements.
The CERT program is comprised of two contractors: the CERT RC and the CERT SC.
The CERT RC performs the following activities:
CERT Documentation Center
1510 East Parham Road
Henrico, VA 23228
Fax: 804-261-8100
Customer Service: 443-663-2699
Toll Free: 888-779-7477
Email: CERTprovider@nciinc.com
The CERT SC performs the following activities:
A stratified random sample of Medicare FFS claims is selected for review; an ADR is issued to retrieve the supporting documentation from the provider or supplier who submitted the claim for payment; and the documentation is reviewed by independent medical reviewers to determine if the claim was paid properly under Medicare coverage, coding, and billing rules.
The CERT RC attempts initial telephone contact with the provider to explain the program and follow up with a faxed or mailed ADR. The provider shall respond to the ADR and forward documentation to support all services and dates of service indicated on the selected claim.
The provider may submit this documentation in any of the following ways:
If these criteria are not met or the provider fails to submit all medical records to support the claim billed, the claim is counted as either a total or partial improper payment and the improper payment may be recouped (for overpayments) or reimbursed (for underpayments). The error is then categorized into one of five major categories: (1) No Documentation, (2) Insufficient Documentation, (3) Medical Necessity, (4) Incorrect Coding, or (5) Other.
The last step in the process is the calculation of the annual Medicare FFS improper payment rate, which is published in the HHS AFR.
Failure to comply with a request for medical records will result in a denial and recovery of payments for all services provided on the claim.
National Government Services receives a monthly CERT notification report of review results and responds to all identified errors (over and underpayments). Claims will be adjusted through National Government Services normal claim adjustment process to allow additional payment if underpaid or recoup any overpayments. Providers will be notified through the normal adjustment process that will include appeal rights.
Any questions regarding the CERT program can be directed to the toll-free number for the Provider Contact Center located in the Contact Us section of our website or the CERT contractor at CERTprovider@nciinc.com.
