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CERT Insider's Guide - Part B Third 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 billion
Ambulance 13.2% $595K (K=million)
Chiropractic services 33.6% $178K
Drugs and biologicals 1.6% $174K

CERT claim reviews

The CERT Insider's Guide provides proactive insight into CERT audit activities for the third quarter of 2025 prior to the finalization of the next CERT report. The following services contributed to the highest improper payment rates by service type for Part B. 

Ambulance

CERT Finding Resolution Resource(s)
Insufficient documentation. Missing physician certification statement for ambulance transport Medical records must support the physician certification statement signed and dated by the beneficiary's attending physician which certifies medical necessity provisions are met CFR, Title 42, Chapter IV, Subchapter B, Part 410, Subpart B, Section 410.40 - Coverage of Ambulance Services
Insufficient documentation. Missing Assignment of Benefits (AOB) to authorize the provider of ambulance services to bill Medicare, signed by the beneficiary or that of his or her representative, if the beneficiary was unable to sign the claim form for ambulance transportation

Medical records must support the Assignment of Benefits (AOB) to authorize the provider of ambulance services to bill Medicare, that was signed by the beneficiary or that of his or her representative if the beneficiary was unable to sign the claim form for ambulance transportation.

If the beneficiary is physically or mentally incapable of signing the claim, the claim may be signed on his or her behalf by one of the following:

  1. The beneficiary's legal guardian.
    A relative or other person who receives social security or other governmental benefits on the beneficiary's behalf.
  2. A relative or other person who arranges for the beneficiary's treatment or exercises other responsibility for his or her affairs.
  3. A representative of an agency or institution that did not furnish the services for which payment is claimed but furnished other care, services, or assistance to the beneficiary.
  4. A representative of the provider or of the nonparticipating hospital claiming payment for services it has furnished if the provider or nonparticipating hospital is unable to have the claim signed in accordance with paragraph (b)(1), (2), (3), or (4) of this section after making reasonable efforts to locate and obtain the signature of one of the individuals specified in paragraph (b)(1), (2), (3), or (4) of this section.
  5. An ambulance provider or supplier with respect to emergency or nonemergency ambulance transport services, if the following conditions and documentation requirements are met.
    1. None of the individuals listed in paragraph (b)(1), (2), (3), or (4) of this section was available or willing to sign the claim on behalf of the beneficiary at the time the service was provided
    2. The ambulance provider or supplier maintains in its files the following information and documentation for a period of at least four years from the date of service:
      1. A contemporaneous statement, signed by an ambulance employee present during the trip to the receiving facility, that, at the time the service was provided, the beneficiary was physically or mentally incapable of signing the claim and that none of the individuals listed in paragraph (b)(1), (2), (3), or (4) of this section were available or willing to sign the claim on behalf of the beneficiary, and
      2. Documentation with the date and time the beneficiary was transported, and the name and location of the facility that received the beneficiary, and
      3. Either of the following:
        1. A signed contemporaneous statement from a representative of the facility that received the beneficiary, which documents the name of the beneficiary and the date and time the beneficiary was received by that facility; or
        2. The requested information from a representative of the hospital or facility using a secondary form of verification obtained at a later date, but prior to submitting the claim to Medicare for payment. Secondary forms of verification include a copy of any of the following:
          1. The signed patient care/trip report
          2. The facility or hospital registration/admission sheet
          3. The patient medical record
          4. The facility or hospital log; or
          5. Other internal facility or hospital records
             

CFR, Title 42, Chapter IV, Subchapter B, Part 424, Subpart C, Section 424.36 - Signature Requirements 

CFR, Title 42, Chapter IV, Subchapter B, Part 410, Subpart B, Section 410.40 - Coverage of Ambulance Services

CFR, Title 42, Chapter IV, Subchapter B, Part 410, Subpart B, Section 410.41- Requirements for Ambulance Suppliers

CMS IOM Medicare Benefit Policy Manual, Pub. 100-02, Chapter 10 - Ambulance Services 

CMS IOM Medicare Claims Processing Manual, Pub. 100-04, Chapter 15 - Ambulance

Specialty: Ambulance
 

Chiropractic services

CERT Finding Resolution Resource(s)
Documentation to support medical necessity is inadequate.
Missing medical necessity supporting active/corrective treatment		 Medical record documentation must include a treatment plan.
Medical record documentation must demonstrate active or corrective treatment. 

Medicare Benefit Policy Manual, Pub. 100-02, Chapter 15 – Covered Medical and Other Health Services, Sections 30.5, “Chiropractor’s Services” and 240, “Chiropractic Services General”

Medicare Processing Manual, Pub. 100-04, Chapter 12, Section 220, "Chiropractic Services"

Medicare Learning Network (MLN) Article: 1232664 - Medicare Documentation Job Aid for Chiropractic Doctors

Medicare Needs Better Controls to Prevent Fraud, Waste and Abuse Related to Chiropractic Services

Specialty: Chiropractic services

Drugs and biologicals

CERT Finding Resolution Resource(s)
Documentation to support medical necessity is inadequate

Drugs and biologicals are covered if certain requirements are met:

  • Meet the definition of drugs or biologicals
  • Not usually self-administered by the patients who take them
  • Meet all general requirements for coverage of items as incident to a physician services
  • Must be reasonable and necessary for diagnosis or treatment of illness or injury for which they are administered according to accepted standards of medical practice
  • Not excluded as noncovered immunizations
  • Not been determined by the Food and Drug Administration (FDA) to be less than effective 

CMS IOM Medicare Claims Processing Manual, Chapter 17 - Drugs and Biologicals

Checklist: Drugs and Biologicals
Insufficient documentation Missing amount of drug wastage

Documentation must clearly indicate the number of units administered and amount discarded in the patient's medical record

The JW modifier is applied only to the amount of drug that is discarded:

  • Billed on a separate line with the JW modifier 
     

Medicare Program Discarded Drugs and Biologicals - JW Modifier and JZ Modifier Policy Frequently Asked Questions 

Drugs and biologicals Part B: Using the JW and JZ modifiers

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 seven-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. 

 

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