Summary of Program
CMS implemented the CERT program to measure improper payments in the Medicare fee-for-service (FFS) program. CERT is designed to comply with the Improper Payments Elimination and Recovery Act of 2010 (IPERA); Public Law 111-204. CERT randomly selects a statistical sample of approximately 50,000 claims submitted to Carriers, FIs, and MACs during each reporting period. Claims are reviewed to see if they comply with Medicare coverage, coding, and billing rules, and if not, errors are assigned to the claims.
CERT Process
The CERT Program uses two contractors to review claims and determine whether the claims were paid properly: the CERT Review Contractor and the CERT Documentation Contractor. The CERT Documentation Contractor is responsible for requesting medical records from health care providers that submitted the claims in the sample via a paper letter. When medical records are submitted by the provider, CERT Review contractors review the claims in the sample and the associated medical records to see if the claims complied with Medicare coverage, coding, and billing rules, and, if not, assigning errors to the claims. If medical records are not submitted, CERT classifies the case as a no documentation claim and counts it as an error. Reviews are conducted and claims determined to be paid incorrectly are scored as errors. Some common errors include:
- Insufficient Documentation
- Medical Necessity
- Incorrect Coding
- Duplicate Payment, other billing errors
Claims determined to be paid incorrectly are scored as errors and payments are adjusted. CERT sends providers overpayment letters/notices or make adjustments for claims that were overpaid or underpaid.
The CERT program cannot be considered a measure of fraud. Since the CERT program uses random samples to select claims, reviewers are often unable to see provider-billing patterns that indicate potential fraud when making payment determinations. The CERT program does not, and cannot, label a claim fraudulent. All public reports produced by the CERT program are available through the "CERT Reports".