Claims review programs

The Centers for Medicare & Medicaid Services (CMS) has implemented several review programs to ensure that all Medicare claims are billed and paid correctly in accordance with the law. The main goal of CMS’ Medicare claim review programs is to reduce the volume of payment errors by identifying and addressing billing errors concerning coverage and coding made by providers.

Comprehensive Error Rate Testing (CERT)

CMS created the Comprehensive Error Rate Testing (CERT) program 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. This post-payment claim review program measures national, contractor-specific, and service-specific paid claim error rates.

Medically unlikely edits (MUE)

A medically unlikely edit (MUE) is a unit of service (UOS) edit for a procedure code for services rendered by a single provider/supplier to a single beneficiary on the same date of service. The ideal MUE is the maximum UOS that would be reported for a procedure code on the vast majority of appropriately reported claims. This prepayment claims review program is designed to reduce errors resulting from clerical entries and incorrect coding based on anatomic considerations, procedure code descriptors, procedure coding instructions, established CMS policies, nature of a service/procedure, nature of an analyte, nature of equipment, and unlikely clinical treatment.

National Correct Coding Initiative (NCCI)

The National Correct Coding Initiative is a prepayment claim review program that was developed by CMS to promote national correct coding methodologies and to control improper coding leading to inappropriate payment in Part B claims. CMS bases its coding policies upon coding conventions defined by the American Medical Association in its CPT® manual, coding guidelines developed by national medical societies, national and local policies and edits, an analysis of standard medical and surgical practices, and a review of current coding practices.

Recovery audit contractor (RAC)

The Recovery audit contractor (RAC) program is a post-payment claim review program that is designed to reduce the volume of improper payments within Medicare programs as well as identifying process improvements to reduce or eliminate future improper payments. Connolly Healthcare, Inc. of Wilton, Conn., is the recovery audit contractor (RAC) for region C, which includes Florida, Puerto Rico, and the U.S. Virgin Islands. Connolly Healthcare may be reached at 1-866-360-2507.