National Government Services, Inc. Medicare Monthly Review Part A and B
A Combined Part A and Part B Newsletter

MMR-2007- 11AB, November 2007

Frequently Asked Questions about Comprehensive Error Rate Testing (CERT FAQs)

Q. What is CERT?

A. CERT stands for Comprehensive Error Rate Testing. It is a program established by the Centers for Medicare & Medicaid Services (CMS) to monitor the accuracy of Medicare payments. Through the CERT program, a claim submission error rate is determined and monitored for each provider, every contractor (e.g., carrier, DME, FI) and at a national level.

In addition, CMS is also using the CERT process to recoup Medicare overpayments identified by a CERT contractor.

Q. How can I find out more about the CERT program?

A. The CMS Web site has Web page devoted to the CERT program. This page can be found at : http://www.cms.hhs.gov/cert/ . The CERT contractor also has a Web page: http://www.certcdc.com/certproviderportal/ National Government Services Inc.’s Web site: www.NGSMedicare.com.

Q. If my claim is selected, who reviews the documentation?

A. CMS has hired a CERT contractor who randomly selects a sampling of claims submitted to Medicare per calendar month. The CERT contractor then requests medical records from providers. Upon receiving these records, the claims and medical records are reviewed to determine if the charges submitted are documented and medical necessity is supported.

The claim submission error rate is determined based on the results of this review process.

For more information about CERT, please visit the CMS Web site at: http://www.cms.hhs.gov/cert/ or the CERT Web site at: http://www.certcdc.com/certproviderportal/ .

Q. What should I include in my documentation?

A. Be sure to include any and all documentation pertaining to the date of service in question. Documentation should support that all items billed have been rendered and support the medical necessity of all services.

Q. What if my records are not in my office but at a nursing home or hospital?

A. The provider who received the reimbursement is responsible for obtaining the required documentation, regardless of place of service. The failure to submit the records results in an overpayment against the provider.

Q. Where should I send my documentation?

A. The CERT contractors preferred method for receipt of medical records/documentation is via fax to 240-568-6222. If you are unable to fax it, please mail it to:

CERT Documentation Office
Attn CID #:
9090 Junction Drive, Suite 9
Annapolis Junction, MD 20701

Q. How do I know when the CERT contractor is requesting records?

A. The CERT contractor will mail a letter to your facility requesting records. A sample of this letter can be found on the CMS Web site at:

http://www.certcdc.com/certproviderportal/RequestLetters.aspx .

Q. What if our facility does not mail in the records within the first 90 days?

A. The CERT will mail a total of four (4) letters to a facility to request medical records. After the fourth letter has been sent and 15 days have elapsed, CERT will assume that the services on the claim were not rendered and will process the claim as an overpayment. The adjustment, or money taken back, will appear on your facility’s remittance advice. When a provider fails to submit medical records and CERT recoups payment, this is considered a claim error. The new schedule beginning November 1, 2006 is:

Day 0 Initial Call/Letter
Day 30 Second Call/ Letter
Day 45 Third Call/ Letter
Day 60 OIG Letter
Day 76 Claim scored in error (Reviewed 6/2007)

Q. What is considered a claim error?

A. The CERT contractor selects claims based on claims submitted to Medicare with the assumption is that all claims submitted to Medicare are processed. The following are considered claim errors:

• Any claim that is submitted to Medicare but is not processed (i.e., paid, rejected, or denied);
• Any claim that is submitted to Medicare for services that are not documented in the medical record;
• Any claim that is submitted to Medicare for services that has been coded incorrectly;
• Any claim that is submitted to Medicare and the documentation does not support the medical necessity for the service;
• Any Medicare claim that is requested by CERT and CERT contractor recoups payment; and
• Any CERT request for documentation where no medical records are sent or some of the documentation is missing when sent to the CERT contractor.

Q. How can we track contractor specific Medicare’s claim error rate?

A. CMS will post CERT results on a regular basis. These results can be found on the CERT Web site at: http://www.cms.hhs.gov/cert .