- Section 1 Introduction
- Introduction
- Federal Government Administration
- Fundamentals of Medicare: State Responsibilities
- Fundamentals of Medicare: Participating Providers
- Voluntary and Involuntary Termination of Provider Agreement
- Disclosure of Health Insurance Information
- Privacy Act
- National Provider Identifier
- Legacy Provider Numbers/Provider Transaction Access Numbers (PTANs)
- Medicare Administrative Contractors
- Fundamentals of Medicare: Information References
- Acronyms
- Fundamentals of Medicare: Glossary of Terms
- Section 2 Medicare Basics
- The History of Medicare
- What Is the Medicare Program and How Is It Funded?
- Medicare Eligibility and Premiums
- The Social Security Administration and Medicare Enrollment
- The Medicare Card
- Medicare Part A
- Inpatient Hospital Care
- Skilled Nursing Facility Inpatient Care
- Home Health Care Benefit
- The Hospice Benefit
- Medicare Part B Medical Insurance
- Fundamentals of Medicare - Medicare Program Exclusions
- Medicare Advantage Organizations
- Medicare Secondary Payer
- Supplemental Insurance
- Coordination of Benefits Trading Partners
- Section 3 Fraud and Abuse
- Section 4 Getting Ready to Bill Medicare
Section 3: Fraud and Abuse
Comprehensive Error Rate Testing Process
Table of Contents
- Comprehensive Error Rate Testing Process
- What is CERT?
- Who Performs CERT?
- How Does It Work?
- CERT Information Available from CMS
Comprehensive Error Rate Testing Process
The CERT program is designed to determine if Medicare contractors are processing and paying claims correctly. This section will help you gain a better understanding of what the CERT program is all about and why it is so important to CMS and National Government Services.
What is CERT?
CMS developed the CERT program to determine national, contractor specific, provider compliance error rates, paid claims error rates, and claims processing error rates.
Who Performs CERT?
CERT activities are performed by two contractors: the CDC and the CERT review contractor (CRC).
The CDC, located in Maryland, is responsible for requesting and obtaining the documentation to support the payments for the selected claims. The CDC attempts initial telephone contact with the provider to explain the program and follow up with a faxed or mailed medical record request letter.
The CRC, located in Virginia, reviews the documentation obtained by the CDC to determine if Medicare payment was supported. Services paid incorrectly are considered errors, whether overpaid or underpaid. The CRC then notifies the Medicare contractor to adjust the claim accordingly.
A Joint Operating Agreement (JOA) exists between the CDC and the CRC to guide both contractors in working efficiently together to accomplish the CERT program activities.
How Does It Work?
- The CDC requests a random sample of claims from a provider to review.
- The CRC verifies that the provider billed the claim according to Medicare guidelines, and that contractor decisions were based on sound Medicare policy.
If you receive a letter requesting claims/documentation for CERT, and do not return the information immediately, you will receive telephone contacts and letters every 10–15 days for approximately 75 days.
If you do not return the requested claims/documentation by the 75th day, the claim will be cancelled and any Medicare reimbursement will be recouped. Telephone contacts are also made by National Government Services to ensure that the appropriate staff receiving requests timely.
CERT Information Available from CMS
The CMS established the CERT and the Hospital Payment Monitoring Program (HPMP) programs to monitor and report the accuracy of Medicare fee-for-service payments. The national error rate is calculated using a combination of data from the CERT contractor and HPMP with each component representing about 60–40 percent of the total Medicare fee-for-service dollars paid, respectively.
- The CERT program measures the error rate for claims submitted to A/B MACs and DME MACs
- The HPMP measures the error rate for the QIOs
- The DHHS, OIG produced the Medicare fee-for-service error rates from 1996–2002. The OIG designed a sampling method that estimated only a national dollar weighted fee-for-service paid claims error rate. Beginning in 2003, CMS elected to calculate a provider compliance error rate in addition to the paid claims error rate. The provider compliance error rate measures how well providers prepare Medicare fee-for-service claims for submission.
CMS calculates the Medicare fee-for-service error rate and estimate of improper claim payments using a methodology the OIG approved. The CERT methodology includes:
- Randomly selecting a sample of approximately 120,000 submitted claims
- Requesting medical records from providers who submitted the claims
Reviewing the claims and medical records for compliance with Medicare coverage, coding, and billing rules.
Revised 1/2021