What is CERT? The Comprehensive Error Rate Testing program was created by the Centers for Medicare & Medicaid Services (CMS) to measure the paid claims error rate for Medicare claims submitted to Medicare administrative contractors (MACs), carriers, durable medical equipment regional carriers (DMERCs), and fiscal Intermediaries (FIs) and to ensure that the Medicare program is paying claims correctly. The CERT program measures national, contractor-specific, and service-specific paid claim error rates.
How is CERT administered? The CERT program uses a random and a service-specific sampling of claims methodology. There are two contractors responsible for administering the CERT program on behalf of CMS. The CERT review contractor selects samples of claims from each Medicare claims processing contractor. For each claim selected, the CERT documentation contractor (CDC) requests medical records, from the physicians and suppliers that billed for the services, and prepares the documentation for review.
Why is the medical record important? The review contractor uses medical record documentation to verify that the services were billed correctly and to ensure that the Medicare contractor’s decisions regarding the payment and processing of the claim(s) were accurate and based on sound policy.
Why be concerned? Claims billed, paid, or processed incorrectly are categorized as errors. Claims paid to Medicare providers in error are classified as overpayments or underpayments, and contractors are mandated to issue refund requests for all overpayments. In addition, CERT errors can potentially have corresponding negative impacts on providers (e.g., a provider’s claims being subject to prepayment and/or post-payment review).
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CERT resources center