CERT Insider’s Guide – Part A Second 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) |
| Inpatient rehabilitation facilities (IRFs): Defined as all services with a provider type of inpatient hospitals and inpatient rehab units | 26.5% | $2.0 B |
CERT claim reviews
The Cert Insider’s Guide provides proactive insight into CERT audit activities for the second quarter of 2025 prior to the finalization of the next CERT report. The following IRF claim denials contributed to the highest improper payment rates by service type for Part A.
| CERT Finding | Resolution | Resource(s) |
|---|---|---|
| Pre-admission screening missing |
A pre-admission screening serves as the basis for the initial determination of whether the patient meets the requirements for an IRF admission to be considered reasonable and necessary: Must be completed within 48 hours prior to admission Detailed documentation must justify the patient requires, will benefit from, and is able to actively participate in intensive rehabilitation therapy Conducted by a licensed or certified clinician or rehabilitation physician |
CMS IOM Pub. 100-02, Medicare Benefit Policy, Chapter 1, section 110 Checklist: Inpatient Rehabilitation Facility (IRF) documentation |
| The documentation does not support that the beneficiary requires the active and ongoing therapeutic intervention of multiple therapy disciplines. |
For an IRF stay to be reasonable and necessary, the beneficiary must require active and ongoing intervention of multiple therapy disciplines: Physical therapy (PT), occupational therapy (OT), speech language pathology (SLP), or prosthetics/orthotics, with at least one being PT or OT |
Checklist: Inpatient Rehabilitation Facility (IRF) documentation
|
| The documentation does not support that the beneficiary can reasonably be expected to actively participate in, and benefit significantly from, the intensive rehabilitation therapy program. |
One criterion for an IRF stay to be considered reasonable and necessary is an intensive rehabilitation therapy program is required: Generally accepted standard of care is 1-on-1 therapy, generally consisting of 3 hours per day, 5 days per week In certain well-documented cases, this intensive rehabilitation might consist of at least 15 hours of therapy within a 7 consecutive day period, beginning with the date of admission to the IRF Required therapy treatment begins within 36 hours from midnight of the day of admission to the IRF: Group therapy is acceptable but may not constitute most of the therapy: Justification for the use of group therapies must be documented in the medical record |
CMS IOM Pub. 100-02, Medicare Benefit Policy, Chapter 1, section 110 Checklist: Inpatient Rehabilitation Facility (IRF) documentation |
| Interdisciplinary team (IDT) meeting notes/records – Missing |
IDT meetings must be led by a rehab physician either in person or remotely via a mode of communication such as video or telephone conferencing, who documents concurrence with all decisions made at each meeting: IDT meetings held at minimum of once a week: A week is 7 calendar days beginning with the admission day counting as day 1 If a patient is admitted to an IRF on the day IDT meetings are scheduled, CMS expects all patients in the IRF to be discussed during that meeting CMS will permit IDT meetings to be completed by day 8 of a patient's stay in certain circumstances |
CMS IOM Pub. 100-02, Medicare Benefit Policy, Chapter 1, section 110 Checklist: Inpatient Rehabilitation Facility (IRF) documentation |
| The documentation does not support a reasonable expectation that at the time of admission to the IRF the patient’s medical management and rehabilitation needs required an inpatient stay and close physician involvement - - plan of care (POC) missing |
The overall POC is developed by the rehabilitation physician with input from the interdisciplinary team: Must completed within 4 days of the IRF admission Detailed information related to the patient’s medical prognosis and the anticipated interventions (PT, OT, SLP, and prosthetic/orthotic therapies), functional outcomes, and discharge destination from the IRF stay must be included Supports the medical necessity of the IRF admission |
CMS IOM Pub. 100-02, Medicare Benefit Policy, Chapter 1, section 110 Checklist: Inpatient Rehabilitation Facility (IRF) documentation |
IRF benefit
The inpatient rehabilitation facility (IRF) benefit is designed to provide intensive rehabilitation therapy in a resource intensive inpatient hospital environment for patients who, due to the complexity of their nursing, medical management, and rehabilitation needs, require and can reasonably be expected to benefit from an inpatient stay and an interdisciplinary team approach to the delivery of rehabilitation care.
The IRF benefit is not to be used as an alternative to completion of the full course of treatment in the referring hospital. A patient who has not yet completed the full course of treatment in the referring hospital is expected to remain in the referring hospital, with appropriate rehabilitative treatment provided, until such time as the patient has completed the full course of treatment. Though medical management can be performed in an IRF, patients must be able to actively participate in and benefit from the intensive rehabilitation therapy program provided in IRFs in order for an IRF claim to be considered reasonable and necessary, in accordance with 42 CFR § 412.622(a)(3)(ii)
Therefore, patients who are not able to actively participate in and benefit from the intensive rehabilitation therapy services because they are still completing their course of treatment in the referring hospital should remain in the referring hospital until they are able to do so. Conversely, the IRF benefit is not appropriate for patients who have completed their full course of treatment in the referring hospital, but do not require intensive rehabilitation. Medicare benefits are available for such patients in a less-intensive setting.
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 On-Demand Learning to view webinar recordings and click-and-play videos.
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