cert audits

One of the newest acronyms that our law firm has encountered in the Medicare Program’s audit process is the Medicare Comprehensive Error Rate Testing program audit or CERT audit.  It could be that we just haven’t had clients who had problems with this in the past, as we have seen plenty of Zone Program Integrity Contractor (ZPIC) audits, Medicare Administrative Contractor (MAC) audits and actions, Medicaid Fraud Control Unit (MFCU) audits, etc.  However, we did have a client recently who was being audited by a CERT contractor and we assisted in resolving document discrepancies.

The Centers for Medicare & Medicaid Services (CMS) created the Comprehensive Error Rate Testing (CERT) program to measure the paid claims error rate for Medicare claims submitted to Medicare administrative contractors, carriers, durable medical equipment regional carriers, and fiscal intermediaries (now Medicare Administrative Contractors or MACs) .  CMS receives in excess of two billion claims annually.  The CERT program randomly selects approximately 120,000 of these claims for review to determine whether the claims were properly paid.

Statistical samples are selected and the CERT documentation contractor (CDC) submits documentation requests to those providers who submitted affected claims.  Once the requested documentation has been received, the information is forwarded to the “CERT review contractor” (or CRC) for review.  The CRC will review the claims and supporting documentation to measure compliance with Medicare coverage, coding and billing rules.

As with many audits, it  seems like the most common problems being detected have to do with medical records errors, such as the documentation not supporting the code billed, absence of signatures on medical record entries, wrong dates of service, absence of medical record documentation, illegible records, wrong provider being billed for, etc.

We have been pleasantly surprised, however, when our personal phone calls to CDC and the CRC have been answered and actual accurate information provided, as well as letters and documents we provided being promptly acknowledged.  Like with any other audit, however, we urge those being audited to seek the advice of an experienced health law attorney who may be able to assist in heading off and avoiding a more serious investigation or a large repayment demand eventually resulting.

For more info see:  http://www.cms.gov/MLNProducts/downloads/MCRP_Booklet.pdf

or visit our website at:  www.TheHealthLawFirm.com