Medicare Compliance & Reimbursement

Hint: It’s complicated.

As a Medicare provider, you may be accustomed to checking with the Medicare Administrative Contractor (MAC) in your jurisdiction for clarity on a variety of subjects — and that’s also the case with the Comprehensive Error Rate Testing (CERT) audit program. However, the part your MAC plays in the CERT review cycle can be confusing and stands apart from other Medicare audit types.

That’s why understanding how your MAC factors into the CERT review process can be especially critical because these audits are complex, and you will likely need their guidance or input at one point or another. Test your knowledge on the intersection of MACs and the CERT program with these eight questions and answers.

Question 1: True or false. Your MAC will perform your CERT audit.

Answer 1: False. CERT contractors perform the audits, not the MACs. The CERT Review Contractor’s (RC) job “is to request, maintain and review sampled medical records to determine if the claims were appropriately paid,” MAC Palmetto GBA explains in online guidance. CMS contracts with outside firm Empower AI, Inc. to complete these audits.

Question 2: True or false. MACs are behind the sampling strategy that CMS uses to determine the improper payment rate.

Answer 2: False. In actuality, CMS devised the CERT program to investigate the claims processing accuracy of the MACs, so they are not part of the review methodology. CMS uses a different contractor for that function, the CERT Statistical Contractor (SC). Currently, the Lewin Group, Inc. acts as the CERT SC and “designs how the claims are sampled and calculates the improper payment rates,” Palmetto says.

Question 3: True or false. CERT contractors only look at provider and supplier’s denied Medicare claims.

Answer 3: False. CERT contractors use a random sampling of claims from each of the MACs, including both paid and denied claims.

Question 4: True or false. Independent CERT contractors pull only one claim from a provider as opposed to many, which is different from how other audit programs operate and evaluate.

Answer 4: True. The CERT contractor’s reviews cover the entire nation versus just one MAC or provider/supplier. They pull upwards of 50,000 claims a year from each individual MAC.

Question 5: True or false. MACs use data in the CERT findings to create educational programs for providers and suppliers.

Answer 5: True. “The results of the CERT reviews are used to calculate the national improper payment rate, which measures how we [MACs] are doing,” expounds CGS Medicare’s Julene Lienard in a webinar for the Part B MAC. “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.”

Lienard adds, “When we see there’s maybe a problem, then we will educate on a grander scale.”

Question 6: True or false. Your MAC may adjust your claim after it gets the audit results.

Answer 6: True. MACs “adjust claims based on [a] CERT contractor’s review decision,” CMS notes in the CERT A/B MAC Outreach & Education Task Force guidance. “Claim adjustment can result in an underpayment or overpayment,” the agency warns.

Question 7: True or false. CERT contractors are the ones who collect overpayments post-review.

Answer 7: False. “MACs, like us, are required to pursue overpayments resulting from CERT errors,” notes Part B MAC Novitas Solutions. “We adjust the original claim accordingly and send a demand letter to the provider who was paid for the service(s) billed. The demand letter specifies the reason for the CERT denial/reduction, and includes information regarding recourse under this process.”

Question 8: True or false. Providers and suppliers do have the right to appeal the CERT contractor’s decision and do so through the independent reviewer.

Answer 8: True and false. Yes, providers/suppliers can appeal their CERT audit results, but Empower AI and the Lewin Group are not involved. You will direct all CERT appeals to your individual MAC, similar to how you would any other determination.