Talking Medicare: Understanding CERT

Every year around this time, our firm receives a steady stream of questions from AAA members about the CERT Program. Typically, the provider has received a notice from what appears to be the Centers for Medicare and Medicaid Services (CMS), which asks for medical records for one or two patient transports. These providers naturally wonder whether they are being audited, and how they should respond. The intent of this post is to clear up any confusion.

What is the CERT program?

The Comprehensive Error Rate Testing (CERT) program is an attempt by CMS to measure the rate of improper payments in the Medicare Fee-for-Service Program. It does so by evaluating a statistically valid random sample of claims to determine whether these claims were properly paid under the applicable Medicare coverage, coding, and billing rules.

In August 2016, CMS awarded responsibility for conducting CERT reviews to AdvanceMed. Therefore, if you receive a letter from AdvanceMed, and that review is asking for only a single claim, it is likely that you are being asked to participate in the FY 2017 CERT review.

What is the National Error Rate for ambulance services?

In its report for Fiscal Year 2016, CMS indicated that the overall improper payment rate was 11.00% across all provider types. CMS estimated that this represented approximately $41.08 billion in improper payments. This is down slightly from the FY 2015 review, which estimated the improper payment rate at 12.09%, representing $43.33 billion in improper payments. The FY 2016 reporting period ran from July 1, 2014 through June 30, 2015.

The overall error rate for Part A Providers, i.e., hospitals, nursing homes, etc., was 13.98%. The overall error rate for Part B providers was 11.71%.  In contrast, the error rate for durable medical equipment, prosthetics, orthotics, and supplies (DME) was 46.26%.

The overall error rate for ambulance was 11.7%, or basically the same as the overall Part B error rate. The ambulance error rate was further broken down based on the basis for a payment error. The most common error, comprising more than three-fourths of all errors, was either no documentation or insufficient documentation. The lack of medical necessity for the ambulance comprised only 15.6% of all improperly paid ambulance claims.

Should I freak out if my service is selected for review?

In a word, “No.” The odds of your service being selected under the CERT program are quite low. If you are selected, it is helpful to keep in mind that the focus of this review is not on your billing practices. Rather, the focus is on whether your contractor processed your claim correctly. This is not to say that CMS will not attempt to recoup payment on the claim if it ultimately determines that the claim was paid in error; it will. However, from your perspective, that recoupment is the end of the matter.

In other words, the worst that can happen with a CERT review is that you would have to repay that single claim. It will not result in a large extrapolated overpayment. Nor is the denial of that claim likely to trigger a larger postpayment review. Therefore, other than being sure to respond to the record request in a timely fashion, there is little to fear from CERT.

I hope this helps put your mind at ease!

Have an issue you would like to see discussed in a future Talking Medicare blog? Please write to me at bwerfel@aol.com.