Fast facts: CERT claim sampling and review process
CMS created the Comprehensive Error Rate Testing (CERT) program to measure the error rate of improper fee-for-service (FFS) payments. The error rate measures payments that didn’t meet Medicare requirements; it does not indicate fraud.
Claim sampling
A statistically valid random sample of 37,500 Medicare FFS claims submitted between July 1st and June 30th are reviewed annually by an independent medical review contractor to determine if they were paid or denied properly under Medicare coverage, coding, and billing rules.
- The stratified random sample is chosen by claim type:
- Part A [hospital inpatient prospective payment system (IPPS)]
- Part A (excluding Hospital IPPS)
- Part B
- Durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS)
Medical records are requested from the billing provider or supplier for each claim selected.
Claim reviews
The CERT review contractor’s medical review professionals perform reviews of the submitted medical record documentation to determine whether the claim was paid or denied properly by the MAC. If Medicare coverage, coding, and billing rules criteria are not met or the provider fails to submit medical records to support the claim billed, the claim is counted as either a total or partial improper payment.
- Claim review professionals include nurses, medical doctors, and certified coders
- Medical review professionals assign improper payment error categories such as insufficient documentation, medical necessity, incorrect coding, no documentation, or other
This improper payment amount may be recouped (overpayments) or reimbursed (underpayments).
Claim review reporting
After the reviews are completed, the improper payment rate is calculated and is published annually in the Health and Human Services (HHS) Agency Financial Report (AFR).
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