Knowledge Base Article

In the world of Medicare & Medicaid Review Contractors the Comprehensive Error Rate Testing (CERT) Program performs audits to see how well Medicare Administrative Contractors (MACs) are adjudicating claims. CMS released Change Request 10778 (CR10778) on June 15, 2018 with an effective date of July 17, 2018. This transmittal updates Chapter 12, The Comprehensive Error Rate Testing (CERT) Program, of the Medicare Program Integrity Manual (PIM). Specifically, CR 10778 updates Chapter 12, section 12.3.8 with details on no response and insufficient documentation errors in the CERT Program. Before we look at the “details” let’s set the stage with a little more about the CERT.

About the CERT

The CERT Program calculates the Medicare Fee-for-Service (FFS) program improper payment rate. Any claim paid when it should have been denied or paid at a different amount is considered to be an improper payment by the CERT. Annually, a stratified sample of approximately 50,000 claims that have been submitted to Part A/B Medicare Administrative Contractors (MACs) and Durable Medical Equipment MACs are reviewed to determine if they have been paid properly under Medicare coverage, coding, and billing rules.

Claims are counted as total or partial improper payment and the error is categorized into one of the following five major categories:

1. No Documentation,
2. Insufficient Documentation,
3. Medical Necessity,
4. Incorrect Coding, or
5. Other.

The CMS CERT webpage and the CERT Review Contractor website both emphasize that “it is important to note the improper rate is not a fraud rate, but is a measurement of payments made that did not meet Medicare requirements.”

CR 10778

The CERT Review Contractor issues an Additional Documentation Request (ADR) to obtain medical records from providers. They currently have processes in place to report to the MACs when there is no response from a Provider or they receive insufficient documentation. CR10078 provides information to the MACs on actions they may take for these two types of errors.

Key Changes Effective July 17, 2018

The PIM, Chapter 12, section 12.3.8 is currently titled “Contacting Non-Responders and Documentation Requests” and was last updated January 19, 2017. The remainder of this article focuses on the details of what is changing. Specific changes in CR10778 are bolded and italicized.

Title Change

• Current Title: Contacting Non-Responders and Documentation Requests
• Effective July 17, 2018: “Handling Non-Responders and Insufficient Responses to Additional Documentation Requests (ADR)”

Additional Documentation Requests

• Current Guidance: A MAC may contact providers when an additional documentation request (ADR) is issued. ADR claims can be found on the CERT Claims Status Website (CSW).
• Effective July 17, 2018: The CERT review contractor sends the additional documentation request (ADR) to the billing provider and/or supplier. If the CERT review contractor determines that the documentation is missing or insufficient to make a determination on a claim, a subsequent ADR may be sent to the billing provider and/or supplier, the ordering/referring provider, or a third-party, as appropriate.

Contacting Non-Responders

• Effective July 17, 2018: This section will be re-titled “Handling Non-Responders” and include the following guidance.
  

If no response is received within the allotted time of 75 days, the CERT review contractor shall find the claim in error and assign Error Code 99 to the claim. These claims are posted to the Claims Status website (CSW) on the 76th day from the date the first request letter was sent. In addition, claims with Error Code 99 will appear in the next MAC feedback batch.

For claims with Error Code 99, the MACs may proceed at their discretion by doing one of the following:

1. Contact those providers who have failed to submit medical records and encourage them to submit the requested records to the CERT review contractor for review. The MACs should allow feedback to roll over as long as they are working with the provider to obtain documentation and/or CERT is reviewing the claim;
2. Complete MAC feedback, prior to entering an appeal, in accordance with section 12.3.3.3 of this chapter and collect the overpayment immediately in accordance with section 12.3.4 of this chapter; or
3. Collect the overpayment within 10 business days of the deadline for entering the final MAC feedback.
   

The MAC shall not contact any provider and/or supplier selected for CERT review until 30 days after the CERT first ADR has been reported on the CSW. The MAC may contact the third party and encourage them to send the needed medical record documentation to the CERT review contractor. When contacting the provider and/or supplier, the MAC shall remind them to include the barcoded cover sheet included with the CERT request or the CERT claim identification number at the top of the medical record. The MAC can download a barcoded cover sheet from the CSW if needed.

Handling Insufficient Responses – NEW

If the documentation submitted is inadequate to support payment for the service/item billed, or if the CERT review contractor could not conclude that the billed service/item was actually provided, was provided at the level billed, and/or was medically necessary, then the claim is considered to be an error due to insufficient documentation. Insufficient documentation errors are assigned an Error Code 21.

Claims that receive an Error Code 21 will be posted under the MAC feedback section of the CSW. MACs should reach out to the providers/suppliers to submit the requested documentation to the CERT review contractor.

Documentation Request Letters

When requesting medical records from providers, suppliers, and/or third parties, the CERT review contractor uses the CMS approved request letters, found at https://certprovider.admedcorp.com/. The CERT review contractor also sends the request letters in Spanish to providers in Puerto Rico and upon request to providers in other regions. (Note, this is an updated email address to use to find the CMS approved request letters.)

CERT Program, MACs and Hospitals

In their 2017 Medicare Fee-for-Service Supplemental Improper Payment Data Report, the CERT found a 9.5 percent improper payment rate in claims reviewed that had been submitted for payment from July 1, 2015 through June 30, 2016. “No documentation” errors accounted for 2% of the monetary loss findings and “insufficient documentation” errors accounted for 64% of the monetary loss findings. MACs utilize CERT Program review findings as one data source to identify issues for Provider Education and Pre-Payment Reviews. Hospitals need to be aware of the errors, educate key stakeholders within your facility and respond to ADR requests from the CERT.