Part B Insider (Multispecialty) Coding Alert

Be aware of the nuances between CERT and other claims review programs.

If you’re fuzzy on what the CERT program is, why the data is collected and studied, and how it can help your Medicare Part B practice, read on for the scoop.

CGS Medicare’s Julene Lienard offered insight on how the Comprehensive Error Rate Testing (CERT) program collects and utilizes providers’ Medicare fee-for-service (FFS) claims data in the Part B payer’s April 25 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 (CMS) 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 explains. “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 says. “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 says.

“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 says. “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 continues, “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 Documentation Requests Work

The Additional Documentation Request (ADR) process for the CERT program is similar to other audit types, but it’s important to know the minutiae to avoid confusion. Take a look at these seven 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 says. 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 maintains.

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 — maybe just one line was in error — and this improper payment gets recouped,” she cautions.

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 adds.

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 notes. This data is what the U.S. 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 indicates.

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,” Lienard points out.

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