Knowledge Base Article

Q:

Have Medicare Contractors started performing Medical Reviews again?

A:

In last week’s newsletter we answered this question by reviewing recent CMS Guidance regarding Medicare Administrative Contractors (MACs), Supplemental Medical Review Contractor (SMRC) and Recovery Audit Contractor (RAC) resuming medical reviews.

Since then, the Comprehensive Error Rate Testing (CERT) has posted the following notice on the CMS CERT webpage: 

“Effective August 11, 2020, the Centers for Medicare & Medicaid Services (CMS) is resuming Comprehensive Error Rate Testing (CERT) program activities that were temporarily suspended in response to the public health emergency (PHE) for the 2019-Novel Coronavirus (COVID-19) pandemic. Specifically, the CERT program will resume sending documentation request letters to and conducting phone calls with providers or suppliers to request medical documentation for claims in Reporting Year (RY) 2021 (claims submitted 7/1/2019 through 6/30/2020) and RY 2022 (claims submitted 7/1/2020 through 6/30/2021).  

Due to the cyclical nature of the CERT program improper payment measurement and the statutory timeline required for improper payment reporting under the Payment Integrity Information Act of 2019 (PIIA) (i.e., reporting annually), improper payment measurements cannot pause for an extended period without missing the statutorily required due dates.  

The CERT program will not resume sending documentation request letters to, or conducting phone calls with, providers or suppliers to request medical documentation for claims in RY 2020 (claims submitted 7/1/2018 through 6/30/2019). The CERT program will report the 2020 Medicare Fee-for-Service (FFS) program improper payment rate in the November 2020 Department of Health and Human Service (HHS) Agency Financial Report (AFR) based on the data that CMS currently has or that providers or suppliers voluntarily submit.

CMS has altered CERT program activities in the short term (i.e., ceasing provider contact for RY 2020 claims) and adjusted data collection in the longer term (i.e., sample size reduction for RY 2021 and RY 2022 claims) to account for the challenges incurred by providers and suppliers during the PHE, while continuing to maintain appropriate accountability measures and meet statutory obligations.”