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CERT: What You Need to Know
Ann Florer, RN, CCS-P
Corporate Compliance Analyst
In FY 2000, the Center for Medicare and Medicaid Services (CMS) initiated the Comprehensive Error Rate Test (CERT) program. The CERT program was designed to determine the cause for claim errors and to develop appropriate action plans to improve compliance with payment, claims processing, and provider billing requirements. The CERT error rate is based on payments for claims submitted to the associated CMS contractors (carriers, fiscal intermediaries, and durable medical equipment regional carriers).
CMS uses the results of the CERT program along with the Hospital Payment Monitoring Program (established to produce an error report for inpatient acute care claims) to produce an overall Medicare fee-for service error rate. CMS uses this error rate to provide an annual estimate to Congress of the amount of improper payments for Medicare fee-for-service claims pursuant to the Improper Payments Information Act of 2002 (Public Law 107-300).
In reviewing claims and medical records, the CERT contractor follows Medicare regulations, national coverage decisions, coverage provisions in interpretive manuals, and affiliated contractors' local medical review policies. In the absence of written criteria, the CERT medical review specialists apply their clinical expertise.
Through the CERT program, CMS randomly selects approximately 140,000 claims each calendar year. Medical records are requested from submitted provider claims and reviewed for compliance with Medicare coverage, coding and billing rules. Claims are considered errors and overpayment letters will be sent if a provider fails to submit the requested documentation, provides insufficient documentation or if the medical record indicates the services billed were not medically necessary, coded incorrectly or not in compliance with other Medicare rules and regulations.
What you need to know if you receive a CERT request:
- Promptly provide the requested medical documentation
- You are not violating HIPAA by providing this documentation
- You do not need additional patient authorization to submit documentation to the CERT contractor
- Keep your Medicare enrollment information current
A CMS fact sheet regarding the CERT Program can be found by clicking:
http://www.cms.hhs.gov/MLNProducts/downloads/certfactsheetv1-3.pdf
References
The information contained herein is provided for informational and educational purposes only, and nothing contained herein should be construed as advice. All information contained herein is obtained by LYNX Medical Systems (LYNX) from sources believed by LYNX to be accurate and reliable. Because of the possibility of human and mechanical error as well as other factors, LYNX is not responsible for any errors or omissions. LYNX makes no representations and disclaims all expressed, implied, and statutory warranties of any kind to user and/or any third party including warranties as to accuracy, timeliness, completeness, merchantability or fitness for any particular purpose.