CERT Insider’s Guide

Comprehensive Error Rate Testing (CERT) program background

The CERT program measures payment compliance with Medicare fee-for-service (FFS) program federal rules, regulations, and requirements and calculate 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. 

Who are the CERT contractors?

The current CERT contractors are:

• CERT Review Contractor – Empower AI, Inc. (formerly known as NCI Information Systems, Inc.)
  • Samples claims
  • Requests and receives all medical records
  • Images medical records
  • Performs quality control of all imaged records
  • Furnishes provider customer service and education support
  • Reviews medical records
  • Compiles the data for the CERT Statistical Contractor
  • Maintains the CERT provider website
  • Maintains the CERT claim status website used by the MACs
  • Maintains the CERT management website used by CMS
• CERT Statistical Contractor – The Lewin Group, Inc.
  • Calculates improper payment rates and amounts
  • Designs sampling strategy
  • Maintains the Live Data Dashboard

Contact information:

CERT Documentation Center
8701 Park Central Drive, Suite 400-A
Richmond, VA 23227
Fax: 804-261-8100
Toll Free: 888-779-7477
Email: certprovider@empower.ai

How will I know if I am selected for review by the CERT contractor?

The CERT review contractor will issue an additional documentation request (ADR) to the provider requesting medical records for each claim sampled for CERT review. ADRs are sent to the provider's medical record corresponding mailing address provided on the most recent provider enrollment application; however, providers can request a change to this address for subsequent letters.

• How to change or add a practice mailing address
• First Coast YouTube tutorial: MAC Medical Review Best Practices: Updating Your Contact Information
• C3HUB letter and contact information

Providers have 45 days to respond to the letter with supporting documentation (initial request schedule). 

Do not ignore CERT ADRs. Failure to respond completely or timely will result in the assignment of an improper payment error and the recoupment of Medicare payments.

How do I respond to an ADR and what should I send?

The CERT ADR will outline the following:

• The purpose of the CERT program and the requirement to respond
• List medical record documents that are being requested
• The name of the patient and dates of service for which documentation is being requested
• Instructions for submitting the documentation to the CERT documentation office

Submit all documentation substantiating the services billed to Medicare. If this requires coordination with third parties to obtain and submit the necessary documentation to fulfill the CERT request, please do so in a timely manner. 

• Sample request letters 

Prior to submitting documentation, make sure that all photocopies are legible and complete with beneficiary identification. Ensure the documentation contains both sides of each page (including page edges). In addition, attach the bar-coded cover sheet provided by CERT that accompanied the request letter to the front of the applicable claim documentation. The CERT contractor will assign a unique 7-digit identifier to each claim. The claim identification number (CID) is found on the CERT ADR.

ADR response assistance

The CERT contractor provides document request listings to assist providers in responding with the necessary documentation to support a Medicare claim. First Coast also provides Part A and Part B documentation checklists.

What is an improper payment?

The CERT program requests supporting documentation from providers or suppliers who submitted the claim for payment and then uses independent medical reviewers to determine if the claim was paid properly under Medicare coverage, coding, and billing rules. When assessing an improper payment, the reviewer will categorize the finding into one of the following major categories:

• No documentation
• Insufficient documentation
• Medical necessity
• Incorrect coding
• Other

An improper payment is a payment that should not have been made or payments made in an incorrect amount. Overpayments and underpayments are considered improper payments. Improper payments can include:

• Payments to an ineligible recipient
• Payments for an ineligible service
• Duplicate payments
• Payments for services not received
• Payments for an incorrect amount

An improper payment rate is not a 'fraud' rate, but rather a measurement of payments that did not or could not be proven to meet Medicare requirements.

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.

For report year 2024, the top error categories were:

• Skilled nursing facility
• Evaluation and management services
• Hospital inpatient and outpatient services
• Laboratory testing

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

• CERT
• CERT reports
• CERT resources center
• C3HUB - The CERT C3HUB website is designed to provide Medicare providers, suppliers, and contractors with information about the CERT program and to facilitate coordination, collaboration, and communications between all stakeholders.