Knowledge Base Article

As the summer winds down and school is fast approaching, it takes me back to all the hours of taking notes, studying and then having to take tests. Just like a test in school is a reflection of
how well you have learned what you are being taught, in the world of Medicare & Medicaid Review Contractors the Comprehensive Error Rate Testing (CERT) Contractor performs audits to see how well Medicare Administrative Contractors (MACs) are adjudicating claims.

Error Rate Testing, a Historical Perspective:

• From 1996 through 2002 the HHS Office of Inspector General (OIG) estimated the Medicare Fee-for-Service (FFS) error rate.
• The Centers for Medicare and Medicaid Services (CMS) took over responsibility for the error rate measurement programs in FY 2003. At this time the sample size for the program increased from approximately 6,000 claims to approximately 120,000 claims thus allowing for the projection of a national error rate and for the first time for contractor and service level error rates.

CERT Review Process:

• The purpose of CERT reviews is to measure improper payments.
• The volume of claims reviewed is small.
• Claims are randomly selected from all claims submitted for payment.
• Claims reviewed are only post-payment complex reviews.
• The CERT Documentation Contractor requests medical records.
• If a provider does not submit the requested record, this counts as an improper payment and the payment is recouped from the providers.
• At least one nurse at the CERT Review Contractor will review the claim.
• Claims that are determined to be incorrect are scored as an error and payments are adjusted.
• Major Causes of Improper Claims includes:
• Missing Physician orders
• Illegible or missing signatures
• National Coverage Determinations (NCDs) or Local Coverage Determinations (LCDs) not being met; and
• The medical record does not support the medical necessity.

2010 CERT Report by the Numbers:

The CERT publishes an annual Improper Payment Report. The most recent report released November 22, 2011 reports the error rate and findings for 2010.

• The 2010 Medicare Fee-for-Service (FFS) paid claims error rate was 10.5% which equates to $34.3 billion in improper payments.
• Improper payments for inpatient hospital claims increased significantly from 2009 with inappropriate “place of service” errors accounting for a projected $5.1 billion.
• The Medicare Part B error rate decreased from 18.9% in 2009 to 12.9% in 2010.
• The Medicare Part A non-inpatient hospital claims decreased from 8.8% in 2009 to 4.2% in 2010.

What does the Medicare Administrative Contractor (MAC) do with the CERT Findings?

• Utilizes the findings to determine issues for Provider Education and Pre-Payment Reviews.

To learn more about the CERT visit the CMS CERT web page.