The Centers for Medicare & Medicaid Services (CMS) developed the Comprehensive Error Rate Testing (CERT) program to calculate the Medicare Fee-for-Service (FFS) program improper payment rate. The CERT program considers any claim that was paid when it should have been denied or paid at another amount (including both overpayments and underpayments) to be an improper payment. To meet this objective, a stratified random sample of Medicare FFS claims is selected for review; supporting documentation is retrieved from the provider or supplier who submitted the claim for payment; and the documentation is reviewed by independent medical reviewers to determine if the claim was paid properly under Medicare coverage, coding, and billing rules. If the documentation does not support that the rules were met, the claim is counted as either a total or partial improper payment. The error is then categorized into one of five major categories: (1) No Documentation, (2) Insufficient Documentation, (3) Medical Necessity, (4) Incorrect Coding, or (5) Other.
The CERT program calculates improper payment rates based on the results of the reviews conducted. These rates include an overall national Medicare FFS improper payment rate and improper payment rates for each claim type [Part A inpatient hospital prospective payment system (PPS); Part A excluding inpatient hospital PPS; Part B; and durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS)]. The CERT program ensures a statistically valid random sample; therefore, the improper payment rate calculated from this sample is considered to be reflective of all of claims processed by Medicare FFS program during the report period. CMS also uses the CERT program to perform special studies and supplemental measurements to determine the improper payment rates of particular claim types. The CERT program is also capable of producing other statistical measurements, such as error-prone provider rates. Calculations of these rates facilitate CMS ability to take appropriate corrective actions to reduce improper payments.
It is important to note the improper payment rate is not a fraud rate, but is a measurement of payments made that did not meet Medicare requirements.
Your assistance by furnishing complete documentation in response to requests is critical to producing the most accurate review results data and improper rate calculations.
The CERT program is comprised of two contractors--the CERT Review Contractor (CERT RC) and the CERT Statistical Contractor (CERT SC).
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