Medicare Compliance & Reimbursement

Even if your practice’s coders are stellar and never miss a beat, there’s always room for improvement. Medicare has a plethora of rules and requirements that make billing complicated, and CERT data can be a helpful tool to circumvent documentation, reporting, and coding problems.

Details: Whether your notes, coding, and compliance policies are spot on or your Medicare claims could use a little help, reviewing the annual Comprehensive Error Rate Testing (CERT) report can help with audit planning, rectifying outlier tendencies, and problem solving. Another bonus, you can compare your practice claims statistics against those of your peers at both the state and national level.

The Centers for Medicare & Medicaid Services (CMS) uses the collected CERT data in a variety of ways, too. First and foremost, CMS uses the CERT results to “monitor and report the accuracy of Medicare Fee-for-Service (FFS) payments,” instructs Part B Medicare Administrative Contractor (MAC) Palmetto GBA in online guidance. The agency also utilizes the CERT auditors’ results to “protect the Medicare Trust Fund by identifying errors and assessing error rates, at both the national and regional levels,” indicates MAC CGS Medicare in its CERT guidance.

Additionally, the feds track error trends, looking at claims anomalies among certain provider types, codes, and services through the CERT program. These findings help CMS pinpoint perennial problem areas that cause the improper payment rate to surge upwards annually, costing taxpayers billions. The agency then uses this critical information to rein in outliers, rectify issues, and promote program integrity, CGS suggests.

Furthermore, the data captured and evaluated by the independent CERT contractors allow CMS to measure how the MACs are doing. “The CERT program is designed to determine if Medicare contractors are processing and paying claims correctly,” notes Part B MAC NGS Medicare in online guidance. Plus, MACs use the CERT information to better determine regional programming and education for providers and suppliers, including tools like the Targeted Probe & Educate (TPE) program and Comparative Billing Reports (CBRs) in a specific jurisdiction.

“CERT is an excellent program that provides extremely helpful information for physicians,” explains Christina Neighbors, MA, CPC, CCC, coding quality auditor for Conifer Health Solutions, Coding Quality & Education Department. “It’s really important for physicians to keep an eye out because there is a lot of overcharging and unnecessary billing for services that lack the proper medical necessity.”