Medicare Compliance & Reimbursement

Question: Our practice is currently in the middle of a Comprehensive Error Rate Testing (CERT) audit, and we’ve already sent a lot of documentation for specific services rendered to Medicare beneficiaries. Yesterday, we received another request for medical records for a patient, whose records we have already submitted. Should we just ignore the most recent request to avoid confusion since we’ve already forwarded this documentation?

Virginia Subscriber

Answer: No, you should never ignore a documentation request from a CERT auditor, even if it seems like a repeat request. The CERT auditors may be looking for something specific that wasn’t included in the original documentation, and that’s why another request has been issued.

Medicare Administrative Contractor (MAC) Palmetto GBA added a CERT question-and-answer fact sheet to its website on June 4, which offers great insight into the CERT process, including multiple documentation requests. “Respond to each request separately. The provider may receive requests for several beneficiaries or just one,” Palmetto advises. “However, multiple requests for the same beneficiary and the same date of service may also be received. Even if you have already submitted the documentation once for that beneficiary, respond again.”

According to Palmetto, “a second request for the same patient and date of service should be carefully reviewed to determine if there was missing information from the first response, or if new information is being requested.”

Reminder: Currently, the Centers for Medicare & Medicaid Services (CMS) uses Empower AI as the CERT Review Contractor. They will be the ones requesting claims information should you be audited, and they prefer all documentation to be submitted through fax.

All requests from the CERT auditor will include a list of the Medicare claims and documentation the reviewer needs to perform the audit as well as a barcoded cover sheet. On return of the requested documentation, you must “attach the barcoded cover sheet every time medical records are submitted,” Palmetto warns. “This cover sheet has a claim identification (CID) number and instructions on how to submit the documentation.”