CERT Insider’s Guide - Part A 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 |
| Skilled nursing facility (SNF) inpatient | 17.9% | $5,635,122,763 |
| SNF outpatient | 11.9% | $24,049,232 |
| SNF inpatient Part B | 8.7% | $224,489,932 |
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 SNF claim denials contributed to the highest improper payment rates by service type for Part A.
| CERT Finding | Resolution | Resource(s) |
|---|---|---|
| Insufficient documentation: Three-day qualifying stay missing or supported in the documentation |
Patient must have a medically necessary, three consecutive day inpatient hospital stay prior to SNF admission:
Inpatient status begins the day the beneficiary is formally admitted as an inpatient to the hospital. The three-day qualifying stay count doesn’t include the discharge day or pre-admission time spent in the emergency room (ER) or outpatient services including observation. |
Medicare Learning Network (MLN) Fact Sheet: MLN9730256 –Skilled Nursing Facility 3-Day Rule Billing
|
| Insufficient documentation: Signature log to support a clear identity of an illegible signature |
Documentation including the physician’s order, the certification and recertification, physician’s progress notes, nurse’s documentation and therapists, requires a legible signature and must be dated. 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. |
MLN905364 – Complying with Medicare Signature Requirements Change Request (CR) 6698: Signature Guidelines for Medical Review Purposes |
| Documentation submitted for review did not include certification/recertification statements for skilled care |
Certifications and recertifications are required to be completed by the physician or non-physician practitioners (NPP). Certifications must be obtained at the time of admission, or as soon thereafter as is reasonable and practicable. The first recertification must be completed no later than the 14th day of inpatient extended care services. A SNF can provide the first recertification earlier, or it can vary the timing of the first recertification within the 14-day period by diagnostic or clinical categories. Subsequent recertifications must be made at intervals not exceeding 30 days. Recertifications may be made at shorter intervals as established by the utilization review committee and the skilled nursing facility. If there was a delayed certification or recertification, submit an explanation for the delay and any medical or other evidence, which the SNF considers relevant for purposes of explaining the delay. |
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| Health Insurance Prospective Payment System (HIPPS) coding errors does not support Minimum Data Set (MDS) reporting of item(s) |
All documentation must support skilled services are reasonable and necessary. Do not forget to send supportive documentation from the look back period to verify medical necessity. Please ensure that the MDS is completed in its entirety and correctly to support each patient's care and medical conditions. Include documentation that supports the primary medical condition and active diagnoses reported on the billed MDS:
|
Minimum Data Set (MDS) 3.0 Resident Assessment Instrument (RAI) Manual
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SNF benefit
Post-hospital extended care services furnished to inpatients of a SNF are a covered Medicare benefit. The term “extended care services” means certain items and services are furnished to an inpatient of a skilled nursing facility (SNF) either directly or under arrangements.
The SNF inpatient benefit is for those patients who need skilled nursing or rehabilitative care following an inpatient hospital stay.
Medicare Part A covers Medicare-certified SNF skilled care. Skilled care is nursing or other rehabilitative services, provided according to physician orders, that:
- Require skills of qualified technical or professional health personnel, like registered nurses, licensed practical (vocational) nurses, physical therapists, occupational therapists, and speech-language pathologists or audiologists
- Are provided directly by, or under general skilled nursing or skilled rehabilitation personnel supervision, to assure patient safety and medically desired results
Skilled care is covered if:
- Patient requires skilled nursing or rehabilitation services on a daily basis
- Daily skilled services can only be provided on inpatient basis in a SNF and
- Services delivered are reasonable and necessary for patient’s illness or injury
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 On-Demand Learningto view webinar recordings and click-and-play videos.
References
- CERT
- CERT program
- Appeals
- Specialty webpage: Skilled nursing facility