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What is CERT?
The Government Performance and Results Act of 1993 established performance measurement standards for all federal agencies. In order to improve the processing and medical decision making involved with payment of Medicare claims, the Centers for Medicare & Medicaid Services (CMS) established the Comprehensive Error Rate Testing (CERT) Program in August 2000. The purpose of the CERT program is to measure and improve the quality and accuracy of Medicare claims submission, processing, and payment.
Under CERT, an independent contractor (AdvanceMed of Richmond, Virginia) will select a random sample of claims processed by each Medicare contractor. AdvanceMed’s medical review staff (to include nurses, physicians, and other qualified healthcare practitioners) will then verify that the contractor decisions regarding the claims were accurate and based on sound policy.
CMS will use the AdvanceMed findings to determine underlying reasons for errors in claims payment or denials, and to implement appropriate corrective actions aimed toward improvements in the accuracy of claims and systems of claims processing.
How Are Providers and Suppliers of Sampled Claims Impacted by CERT?
You may be asked during AdvanceMed’s review to provide more information, such as medical records or certificates of medical necessity, so that AdvanceMed can verify that billing was proper and that claims processing procedures were appropriate. You will be advised what documentation is needed and the name of your contact.
Unfortunately, many providers do not comply with these requests for information. Some providers believe it is a violation of the Health Insurance Portability and Accountability Act (HIPAA) to send patient records to CERT. Please be assured that sending patient records to the CERT contractor is not a HIPAA violation. We strongly urge providers to respond in a timely manner to CERT requests for documentation, as failure to comply with these requests could result in mandatory refund of previously paid claims, or in referral to the Office of Inspector General (OIG). Providers and suppliers will be contacted only if their claim(s) is selected and AdvanceMed requires additional information.
For more information on the CERT Program, click one of the links below (or use the choices under CERT in the left menu).
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