Comprehensive Error Rate Testing (CERT) Program

The Comprehensive Error Rate Testing (CERT) program is an initiative implemented by the Centers for Medicare and Medicaid Services (CMS) in the United States. It is designed to measure the accuracy of Medicare fee-for-service (FFS) payments and identify improper payments made to healthcare providers. The CERT program aims to ensure that Medicare payments are made correctly and in accordance with the applicable rules and regulations.

The CERT program is responsible for calculating the Medicare FFS error rate, which represents the percentage of claims that were paid incorrectly. This error rate is a crucial metric used by CMS to evaluate the effectiveness of its payment systems and identify areas for improvement. By conducting comprehensive reviews of randomly selected claims, the CERT program provides valuable insights into the accuracy of Medicare payments and helps identify common errors and vulnerabilities in the Medicare billing process.

While both the CERT program and the Recovery Audit Contractor (RAC) program are initiatives aimed at reducing improper payments in the healthcare system, they differ in their focus and methodology.

The CERT program primarily focuses on measuring the accuracy of Medicare fee-for-service payments by conducting comprehensive reviews of randomly selected claims. It aims to identify errors and vulnerabilities in the Medicare billing process and provide feedback to healthcare providers to improve their billing practices. The CERT program does not have the authority to recover overpayments or take punitive actions against providers.

On the other hand, the RAC program is responsible for identifying and recovering improper payments made to healthcare providers. RACs are private contractors hired by CMS to conduct audits and reviews of Medicare claims. They have the authority to identify overpayments and underpayments and initiate recovery actions. The RAC program focuses on retrospective audits and targets specific areas of potential fraud, waste, and abuse in Medicare billing.

In summary, the CERT program focuses on measuring payment accuracy and providing feedback to improve billing practices, while the RAC program focuses on identifying and recovering improper payments.

The CERT program publishes annual reports that provide insights into its findings and the error rates associated with Medicare fee-for-service payments. These reports highlight common errors and vulnerabilities in the Medicare billing process. Here are a few examples of findings from CERT program reports:

1. Insufficient documentation: One common error identified by the CERT program is insufficient documentation to support the billed services. This includes missing or incomplete medical records, lack of physician signatures, or inadequate documentation of the medical necessity of the services provided.

2. Incorrect coding: Another frequent error is incorrect coding, where healthcare providers submit claims with incorrect procedure or diagnosis codes. This can lead to improper payments if the codes do not accurately reflect the services provided or the patient's condition.

3. Medical necessity errors: The CERT program often identifies errors related to medical necessity, where services are billed without sufficient justification or fail to meet the criteria for coverage. This can result in improper payments if the services are deemed unnecessary or not medically reasonable.

4. Upcoding and unbundling: Upcoding refers to the practice of billing for a higher level of service than what was actually provided, while unbundling involves billing separately for services that should be billed together as a single procedure. Both practices can lead to overpayments and are closely scrutinized by the CERT program.

These examples highlight the importance of accurate documentation, coding, and adherence to medical necessity guidelines to ensure proper Medicare payments. The CERT program's findings serve as valuable feedback for healthcare providers to improve their billing practices and reduce errors.In conclusion, the Comprehensive Error Rate Testing (CERT) program plays a crucial role in measuring the accuracy of Medicare fee-for-service payments. By conducting comprehensive reviews of randomly selected claims, the CERT program identifies common errors and vulnerabilities in the Medicare billing process. Its findings help CMS evaluate the effectiveness of its payment systems and provide feedback to healthcare providers to improve their billing practices.