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Proper claims payments may seem like a simple numbers game, but the Centers for Medicare and Medicaid Services (CMS) fee for service (FFS) program continues to battle improper payments, whether it’s a claim that was paid when it should have been denied or a claim that was over- or underpaid. To help track the FFS improper payment rate, CMS developed the comprehensive error rate testing (CERT) program in 1996.1,2
Program Basics
To calculate this rate of error, the program requests records from practitioners and analyzes the claims data. Each reporting period, a stratified, random sample of approximately 50,000 claims are selected for review. Because the selection process ensures statistically valid random samples, it provides data indicative of all claims processed by CMS during the reporting period.
For the selected claims, the submitting clinician must provide all supporting documentation, which is then scrutinized by independent medical reviewers to determine if the claim was paid properly under CMS coverage, coding and billing rules. If the documentation does not show all rules were met, the claim is counted as a total or partial improper payment. These errors are then grouped into one of five categories:
- No documentation
- Insufficient documentation
- Medical necessity
- Incorrect coding
- Other
If you are one of the random providers chosen to provide documentation for CERT, you will get a letter requesting the proper information; it is critical that you respond in a timely fashion. The request comes in a clearly marked envelope and the specific reporting requirements are spelled out clearly in the official correspondence.3
If you do not reply or fail to provide the correct documentation as indicated in the request letter, the CMS contractor will automatically initiate claims adjustments or overpayment recoupment for these undocumented services, so be sure to follow the CERT request guidelines closely.
CERT for You
While this sounds like nothing more than the government doing internal quality control and checking to make sure that all CMS carriers and providers are following the rules, it can have significant implications for your practice. This internal study identifies areas of concern for CMS regarding improper payments made for certain claims types based upon statistical evidence—possibly leading to closer monitoring.
For example, if the program identifies a specific CPT code that has increased in frequency, or a particular ICD-10 code that is being used improperly, it could increase the frequency of audits on the local carrier level. If you were a practitioner who submitted those CPT codes often, this could put you on the short list for an audit.
While CERT may make your heart beat a little faster for fear of more audits, also consider the wealth of information this data provides—for free. CERT data is available to all practitioners on the CMS website and is published on an annual basis.3
This is a great crystal ball, of sorts, that allows you to know what CMS considers areas of concern within their payment system. By reviewing this information, you can remain aware of any codes you use regularly in your office that have been flagged by CERT. This is a great way to identify areas that require further attention within your own practice.
The CERT process benefits you both as a taxpayer and as a provider. It is a transparent process that can provide you with useful information that can help identify areas of concern within your practice’s coding and billing patterns in a timely fashion and allow you to potentially modify behaviors to be compliant before a larger issue surfaces.
Send questions and comments to [email protected].
1. Centers for Medicare and Medicaid Services. Comprehensive error rate testing (CERT). www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/Medicare-FFS-Compliance-Programs/CERT. Accessed April 29, 2018. |
