Q1 |
What is the CERT Program? |
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ANSWER: In order to improve the processing and medical decision making involved with payment of Medicare claims, CMS began a new program in August 2000. This program, named Comprehensive Error Rate Testing (CERT), was implemented in order to achieve goals of the Government Performance and Results Act of 1993 which sets performance measurements for Federal agencies. |
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Q2 |
Who is responsible for administering the CERT Program? |
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ANSWER: CERT processes are performed by two independent CERT contractors selected by CMS.
The CERT Documentation Contractor (CDC) is responsible for:
- Requesting and receiving medical record documents,
- Maintaining a document tracking system,
- Providing a Web site for updating supplier addresses and contact information,
- Scanning the medical records into a retrieval system, and
- Operating a call center to answer contractor and supplier questions regarding CERT.
The CERT Review Contractor (CRC)
- Reviews the documentation submitted by the supplier to determine if the claim was originally adjudicated correctly. The CRC currently reviews over 140,000 randomly-selected claims and corresponding medical records each year. The CRC’s medical review staff includes physicians and nurses who can use clinical judgment when necessary in reviewing medical records. Their medical review staff has access to national and local policies, contractor processing guidelines, and automated edits.
- The CRC also calculates national, contractor specific, provider type, and benefit category specific paid claim error rates.
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Q3 |
How are providers alerted that one or more of their claims has been selected for review in the CERT Program? |
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ANSWER: The CDC will send an initial request letter to each provider. If they do not receive the requested documentation within 30 days of the initial letter, it will be followed by a series of letters and phone calls to the provider. All letters will be clearly identified and will contain details about the specific documentation needed. These documents will be reviewed in order to verify that the services billed were delivered and medically necessary and that the claims processing procedures were appropriate. If a claim from your company is selected, you will be provided with details regarding the needed information and the name of a contact person. |
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Q4 |
The letters I’m receiving from the CERT contractor look different than the ones I use to receive. Is there a new CERT contractor? |
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ANSWER: Since the implementation of the CERT program, the CERT Contractor, located in Richmond, VA, has requested medical records, reviewed claims, and produced national, contractor specific, provider type, and benefit category specific paid claim error rates. CMS has decided to streamline the record request and receipt process by contracting with a CERT Contractor, located in Annapolis Junction, MD, to support the claims review process.
During the transition period when the CERT Contractor in Maryland assumes the responsibility for requesting medical records and documentation for the claims review process performed by the CERT Contractor in Virginia, suppliers may receive letters from one or the other contractor requesting additional information. The CERT new request letters are improved with more specificity in terms of the information needed to conduct the review. |
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Q5 |
What documentation should providers send to the CDC? |
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ANSWER: Providers should send all records, including medical records that support the payment of the item(s) billed on the claim.
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Q6 |
How does the CDC log and track the records they request? |
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ANSWER: Every claim sampled in the CERT Program is assigned a Claim Identification Number referred to as a CID. |
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Q7 |
What is the significance of the barcode sheet? |
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ANSWER: The barcode sheet is just another way of identifying a claim selected in the CERT program. Place the bar coded cover sheet in front of the medical records/documentation being submitted for review. Submit multiple records with the corresponding Bar Coded Cover Sheet as separator pages. |
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Q8 |
What if a claim is determined by CERT to have been paid incorrectly? |
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ANSWER: An overpayment or underpayment will be assessed. Overpayments will be recouped for those claims that the CERT program determines were paid incorrectly. Underpayments will be submitted for payment to the provider for the amount in error. Providers should follow normal procedures for submitting appeals if they feel the decision is incorrect. |
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Q9 |
What do providers risk by not responding to the request made by the CDC? |
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ANSWER: If a company does not comply with the request for additional documentation, CIGNA Government Services will make every effort to contact the supplier and obtain records. Providers that do not respond to the CERT request will receive an “error” and will be assessed an overpayment and the overpayment will be recovered from the provider. |
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Q10 |
How are the error rates determined? |
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ANSWER: The CERT Review Contractor (CRC) selects a random sample of claims processed by each Medicare contractor. Their medical review staff (nurses, physicians and other qualified healthcare practitioners) review the submitted documentation in order to verify whether or not the contractor's decisions regarding the claims were accurate and based on sound policy. |
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Q11 |
How does CMS use CERT results? |
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ANSWER: CMS uses the findings to determine underlying reasons for errors in claims payments or denials and to implement appropriate corrective actions aimed toward improvements in the accuracy of claims and systems of claims processing. It is CMS's intent that the Medicare Trust Fund benefit from improved claims accuracy and payment processes. |
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Q12 |
Can I file an appeal if CERT changes the payment decision on one of my claims and denies or reduces payment? |
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ANSWER: Providers who disagree with any denial or reduction are encouraged to file appeals since appeal reversals will be included in the error rate computations. Do not send appeal requests to the CERT Contractors! If you want to file an appeal, follow the instructions listed on the appeals portion of this Web page. |
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