Medicare Compliance & Reimbursement

Tip: Encrypt your emailed documentation per HIPAA, CERT contractor says.

Unless you’re on Medicare’s short list of providers who’ve been underpaid, now is a good time of year to check your claims data and revisit your protocols for how to handle overpayments, Additional Documentation Requests (ADRs), and appeals.

Context: CMS’s new Comprehensive Error Rate Testing (CERT) results were issued on Nov. 30, and show that practices actually made fewer errors in 2018 than in the previous year. Most of the errors were discovered as overpayments — meaning that CMS identified $31.6 billion that went out to Medicare providers in error. Chances are high that Medicare Administrative Contractors (MACs) will be asking for much of that money back, if they haven’t already. In addition, CMS noted that it still owes more than $1.05 billion to providers who were underpaid in FY 2018.

Find Out How to Respond to a CERT Audit

You can respond to a CERT request in several ways, according to Michael Hanna, MPA, CDME, provider outreach and education consultant at CGS-DME MAC Jurisdiction C in Nashville, Tennessee, in a recent webinar. Take a look at Hanna’s advice and other expert tips on CERT correspondence:

• Fax: This is the preferred method, Hanna says. “Always include the barcode sheet as part of your fax package. This simply marries the documentation you’re submitting with that particular date of service the CERT contractor has chosen for a review.”
• esMD: The electronic submission of medical documentation system (esMD) is another option. With this method, you use the gateway you contracted with and follow standard procedure.
• Postal Mail: “If it’s a sizeable amount of documentation, or you’ve already saved it to a CD, you can mail it in,” Hanna adds. If you send a CD, it can only contain TIFFs or PDFs and should be encrypted in line with HIPAA Security Rule standards, according to CERT Review contractor AdvanceMed.
• Email: You may send an encrypted email, but “if [it’s] encrypted, the password and CID# must be provided” with a follow-up phone call or fax, advises AdvanceMed.

Don’t miss: You can make extension requests by telephone only.

Caution: Normally, the CERT contractor grants extensions only in extreme circumstances such as natural disasters like hurricanes, tornadoes, and ongoing fires, according to Hanna.

“But, if you are simply waiting on medical records from the physician, it is possible the CERT contractor may not grant that extension,” Hanna acknowledges. “If that is the case, you should always send the CERT contractor what you have available, and then if they disagree or find something missing or not valid, you do have appeal rights.”

Any claim errors the CERT contractor finds will result in a revised Medicare admittance advice where they will deny that claim and an overpayment demand where they ask you to repay the money, Hanna cautions.

Know Your Appeal Rights

As mentioned previously, you do have appeal rights when it comes to CERT. The MAC Novitas does a good job of identifying how this appeals process works.

The first level of appeal is called a “redetermination.” You must submit your redetermination request in writing and file it within 120 days from the date on your RA (Remittance Advice) or MSN (Medicare Summary Notice).

You must include all of the following information with your appeal request, according to Novitas:

• The patient’s name
• The patient’s Medicare Beneficiary Identifier (MBI)
• The CERT identification (CID) number
• The date CERT made its initial determination
• The service or items you’re requesting the redetermination for
• The date of service
• Both the printed name and signature of the person making the request.
• The printed name and signature of the person making the request
• An explanation of the requestor’s relationship to the providing physician.

When you submit a redetermination request, you must also include any information that supports the coverage of the appealed service. And if the denial happened because you did not respond to an ADR in time, then you must also include the information requested in the ADR, along with your appeal request.

Resource: To learn more about the CERT program, visit www.cms.hhs.gov/CERT/.