CERT Insider’s Guide – Part A Fourth Quarter 2025
Comprehensive Error Rate Testing (CERT) program background
The CERT program measures payment compliance with Medicare fee-for-service (FFS) program federal rules, regulations, requirements, and calculates an improper payment rate. CMS uses the CERT program to calculate a national improper payment rate as well as contractor and service specific improper payment rates using a stratified random sample of claims selected for review.
Fiscal year (FY) 2024 Medicare FFS estimated improper payment rate
The FY 2024 Medicare FFS estimated improper payment rate is 7.66%, representing $31.70 billion in improper payments. The table below outlines the improper payment rate and projected improper payment amount by claim type for FY 2024. The reporting period for this improper payment rate is for claims submitted July 1, 2022, through June 30, 2023.
|
Claim Type |
Improper Payment Rate |
Improper Payment Amount |
|---|---|---|
|
Overall |
7.66% |
$31.70 B (billion) |
|
Comprehensive outpatient rehabilitation facility (CORF) |
45.4% |
$10,823,888 |
CERT claim reviews
The Cert Insider’s Guide provides proactive insight into CERT audit activities for the fourth quarter of 2025 prior to the finalization of the next CERT report. The following CORF claim denials contributed to the highest improper payment rates by service type for Part A.
|
CERT Finding |
Resolution |
Resource(s) |
|---|---|---|
|
Insufficient documentation: Missing therapy treatment note or log for the billed services |
The CORF services must be furnished under a written rehabilitation plan of treatment established and signed by a physician who has recently evaluated the patient. It is expected that the physician will establish the rehabilitation plan of treatment in consultation with the therapist(s) who will provide the actual therapy. The physician wholly establishes the respiratory therapy plan of treatment. The CORF physician or the referring physician for PT, OT, SLP services, must review the plan of treatment at least once every 90 days certifying that the patient needs or continues to need skilled rehabilitation services, the rehabilitation plan of treatment is being followed and that the patient is making progress in attaining the established rehabilitation goals. The 90-day period begins with the first day of rehabilitation therapy. For respiratory therapy services, the CORF physician or the patient’s referring physician must review the rehabilitation plan of treatment at least every 60 days. The 60-day period begins with the first day of respiratory therapy treatment. |
Checklist: Outpatient therapy and rehabilitation services
|
|
Insufficient documentation: Missing physician order or referral for therapy services and the plan of care |
To become a patient of a CORF, the beneficiary must be under the care of a physician who certifies the need for skilled rehabilitation services. The referring physician must advise the CORF of the beneficiary’s medical history, current diagnosis and medical findings, desired rehabilitation goals, and any contraindications to specific activity or intensity of rehabilitation services. CMS requires that any Medicare service provided or ordered must be authenticated by the author - the one who provided or ordered that service. Authentication may be accomplished through the provision of a hand-written or an electronic signature; however, stamp signatures are unacceptable, with one exception (physical disability). When the signature is illegible or missing, submit an attestation statement or a signature log to the documentation to ensure the signature’s authentication. If documentation submitted for medical review does not contain a signature at all, then only a signature attestation will be accepted. |
|
|
Documentation lacking long-term goals and progress toward goals |
Documentation must include a plan of care that shall contain, at minimum the diagnosis, long term treatment goals, and the type, amount, duration and frequency of therapy services. Therapists typically also establish short term goals, such as goals for a week or month of therapy, to help track progress toward the goal for the episode of care. |
Checklist: Outpatient therapy and rehabilitation services
|
|
Respiratory therapy minutes missing |
For respiratory therapy services, the CORF physician or the patient’s referring physician must review the rehabilitation plan of treatment at least every 60 days. The 60-day period begins with the first day of respiratory therapy treatment. Documentation must be included for time-based codes including timed code treatment minutes and total treatment time. |
|
CORF services
The purpose of a CORF is to permit the beneficiary to receive multidisciplinary rehabilitation services at a single location in a coordinated fashion.
CORF services are covered only if related directly to the rehabilitation for the treatment of injured, disabled, or sick patients. CORF services are not covered if not reasonable and necessary for the diagnosis, or treatment of illness, or injury, or to improve the function of a malformed body member.
There are requirements for coverage of CORF services also known as Rules to the Provision of Services. In general, CORF services, except for PT, OT, SLP services, and the single home environment evaluation, must be furnished on the premises of the CORF. PT, OT, and SLP services provided in the home are not covered as CORF services if payment for such services is made under the Medicare home health benefit. Although, PT, OT, and SLP services can be furnished in the patient’s home, most of these services must be provided on the CORF premises for all CORF patients.
Personnel qualification requirements must also be met. The services must be furnished or supervised by qualified personnel. If the rehabilitation goals for PT, OT, SLP or respiratory therapy services are not specified by the referring physician, the CORF physician must establish them.
Provider’s next steps
When a CERT claim is found to be in error, First Coast will have the claim adjusted and will process the overpayment or underpayment.
Providers will not receive a findings letter; however, a demand letter will be mailed to the billing address on file. If you would like to obtain the CERT denial rationale for the claim, contact First Coast and submit a request via email to QuestCERT2@fcso.com. Please do not include any protected health information (PHI) or personally identifiable information (PII), only the 7-digit claim identifier (CID) number is needed to check status or obtain the denial rationale.
If the billing provider disagrees with the CERT decision, they have 120 days from the date of the adjustment to file a level 1 appeal, known as a redetermination. The date of the adjustment can be found on the demand letter. Include any missing or additional documentation you may have to support the billed services with the appeal. Fill out the request for appeal thoroughly and ensure it is signed.
Educational events
First Coast consistently offers live and on-demand educational opportunities to support our providers in achieving Medicare compliance. Visit the events calendar to view upcoming webinars and the On-Demand Learning to view webinar recordings and click-and-play videos.
References