Home Health & Hospice Week

Both home health and hospice error rates climbed in 2021.

CGS’s Julene Lienard offered insight on how the Comprehensive Error Rate Testing program collects and utilizes providers’ Medicare fee-for-service claims data in a recent CGS webinar, “The Importance of Working Together When Responding to Comprehensive Error Rate Testing (CERT) Documentation Requests.”

CERT Is Different Than Other Claims Review Programs

The Centers for Medicare & Medicaid Services devised the CERT program to investigate the claims processing accuracy of the Medicare Administrative Contractors (MACs). By collecting random samplings of claims across the various jurisdictions, CMS is able to judge how each MAC is doing.

But, don’t be fooled, “CERT is not like your other [Medicare claims] audits where they pick a code and then ask you for a range of dates,” Lienard explained. “You may get a CERT request once and not get another one for a while — or you may not get a CERT request” at all, she said. “It’s all just based on a stratified random sample.”

One big difference is that the independent claims reviewers pull only one claim from a provider as opposed to many, which is how other audit programs operate and evaluate. Additionally, the CERT contractor’s reviews cover the entire nation versus just one MAC or provider. They pull about 50,000 claims a year from each MAC, she said.

“A computer [program] picks the random sample … and the results of the CERT reviews are used to calculate the national improper payment rate, which measures how we [MACs] are doing,” Lienard said. “Each contractor, MAC, gets its own specific error rate. This tells us how we are doing at educating you [and] if you know the proper way to bill something.”

She continued, “And when we see there’s maybe a problem, then we will educate on a grander scale — which is what we are doing today.”

7 Steps Clarify How CERT Works

The Additional Documentation Request (ADR) process for the CERT program is similar to other audit types, but it’s important to know the minutia to avoid confusion. Take a look at these eight steps to ensure you get it right.

1. Address the initial ADR request. If the CERT contractor finds an issue with your claim after reviewing the random sampling, “they will request your medical records through an ADR,” Lienard said. This is similar to how your MAC requests a sample of claims for programs like Targeted Probe and Educate.

2. Expect the letter to come to your PECOS address. If an ADR is determined after a review of your claim, “you’ll get a letter to the address you have on file with [Medicare Provider Enrollment, Chain, and Ownership System] PECOS,” according to Lienard.

3. Understand the timeline for ADR return. Once you receive the ADR, you have 45 days to respond and submit the requested materials.

4. Know who is reviewing your ADR. The CERT contractor “has a medical records department that will review the documentation that you send in to make sure that it is meeting all of the Medicare coverage, coding, and billing rules,” Lienard said.

If it doesn’t meet the guidelines as determined by the clinical staff reviewing the ADR, it’s considered an improper payment. This error “can be either a full claim or just a partial … and this improper payment gets recouped,” she cautioned.

5. Anticipate recoupment to move swiftly. After the CERT reviewer sends the MAC the file with the claims they found in error, the MAC sends in the overpayment and a demand letter is forwarded to the provider, Lienard says. However, “if it’s an underpayment, we will reimburse you your money or the difference,” she added.

6. Find the CERT statistics in this annual report. Once the CERT team finishes reviewing and compiles the national data, the Medicare FFS improper payment rate is released. “That gets published in the Department of Health and Human Services Financial Report,” Lienard noted. This data is what Congress looks at to determine whether the system is working correctly and what actions need to be taken to fix the Medicare FFS claims system, she indicated.

History: The home health payment error rate has dropped drastically over the years — until 2021. When the Department of Health and Human Services calculated an improper payment rate under CERT for 2015, the HHA rate came in at a whopping 59 percent. Every year since then it’s fallen — 42 percent for 2016; 32 percent for 2017; a much lower 17.6 percent for 2018; 12.1 percent for 2019; and 9.30 percent for 2020. The 2021 rate crept back up to 10.24 percent (see more details in HCW by AAPC, Vol. XXX, No. 42).

The same trend has occurred for hospices, with a payment error rate of 10.7 percent for 2015 spiking to 15.9 percent for 2016, then falling to 14.7 percent for 2017, 11.7 percent for 2018, 9.7 percent for 2019, and 6.69 percent for 2020. That rate was back up to 7.77 percent for 2021.

For both HH and hospice rates, HHS claims that “the change is not statistically significant.”

7. Don’t confuse CERT with fraud management. “Keep in mind that CERT is not a fraud range … [the contractors] are not looking for fraudulent activity. It is just a measure of payments that did not meet Medicare requirements.”

8. Know the new address. One thing is changing for CERT — where you send your requested records. “Mail medical records for the Comprehensive Error Rate Testing (CERT) Documentation Center to: CERT Documentation Center/8701 Park Central Drive, Suite 400-A/Richmond, VA 23227,” CMS says in the MLN Connects newsletter. “After May 31, the Center will return mail received at the former address,” CMS warns.