Feeling Targeted by Audits? Here’s one that can actually help…

Many CDM Teams are unaware of the scope and implications of CERT audits. Mary Madsen, Senior Manager of Holliday & Associates has summarized the background and potential impact of the CERT program for our customers within this blog post. Read on to learn how CERT audits, reports, and resources can enhance your team’s internal auditing and monitoring.

Medicare contractors pay more than a billion claims each year, and Medicare Fee-For-Service (FFS) expenditures are increasing annually. As part of its mandated oversight, CMS monitors the accuracy of contractor payments for covered, medically necessary, and correctly coded services. (Or as paraphrased by CMS, ensuring the contractor “pays it right”.) CMS established the Comprehensive Error Rate Testing (CERT) program in 2003 when it assumed responsibility for measuring national payment error rates. Previously (from 1996 through 2002), OIG was responsible for monitoring contractor payment accuracy. The CERT Program, although created to monitor the accuracy of claim payments, creates a treasure trove of data that no provider should overlook. CERT data analysis can become a beneficial component of your organization’s internal compliance auditing and charge monitoring programs. The annual CERT Reports provide background on the program as well as specific audit results that can be integrated into providers’ internal auditing and monitoring programs. If you’ve ever wondered how OIG and RAC audit targets are determined, simply look for the high percentage errors in CERT data analysis reports.* This post provides a brief look at CERT audit background, scope, and resources. We encourage CDM Teams to work with others in the organization to identify the CERT audit issues that can be monitored through CDM tools. *2011 CERT Report The chart below displays providers and claims impacted by CERT audits:

Figure 1: Flow of Claims by Provider and Supplier Types through the Medicare Contractor Claims Processing Entities (from CMS 2011 CERT Audit Report)

The CERT Audit Process

On a daily basis, a random sample of outpatient and inpatients claims, stratified by claim type, is selected from all of the claims submitted to a given Medicare claims processing contractor. The claims are then audited to determine whether they were paid properly under Medicare coverage, coding and billing rules. The CERT program considers any claim that was paid when it should have been denied or paid at another amount (including both overpayments and underpayments) to be an improper payment. CERT corrects improper payments by recovering overpayments or issuing reimbursement to providers who have been underpaid. Providers can appeal CERT findings just as they do other CMS audits. Once a claim is identified as part of an audit sample, CERT requests the associated medical records and other pertinent documentation from the provider or supplier. Professional medical reviewers and coders examine complex accounts that cannot be resolved through automated methods (e.g., medical necessity and correct coding determinations). Error rate data is accumulated for analysis and reporting based on audit findings. CMS reports the CERT payment error rate to Congress and annual reports are later published for public display. In 2011, for example, CERT randomly sampled approximately 51,000 Medicare claims (including paid as well as denied claims). This sample size allowed CMS to calculate a national improper payment rate and also contractor- and service-specific improper payment rates. Analysis of audit findings provides CMS and its contractors with valuable information to assist in the development of specific, robust corrective actions to prevent improper payments.

CERT Resources

Resources listing CERT audit findings can be found through CMS, CMS Contractor, and other websites. Annual CERT reports include specific case findings by provider type. (See Exhibit A of this article.) Findings show vulnerabilities relative to documentation, record retention and coding. Issues are categorized; and provider types responsible for the greatest percentage of errors are identified. Claims processing contractors decide what claim types should undergo automated, complex, pre-payment, and/or post-payment reviews based on analyses of their own contractor-specific improper payment data. Each quarter, Medicare contractors post CERT errors on their websites. Review of these CERT reports allows providers to drill down to the CPT and DRG code level to view the most common audit errors. Visit your Medicare Administrative Contractor (MAC) website to obtain the most recent quarterly report for your jurisdiction. As an additional resource, CMS publishes the Medicare Quarterly Provider Compliance Newsletter which contains official guidance on problematic billing errors identified in the past quarter. Reports dating back to October, 2010 include both CERT findings and recovery auditor findings. Newsletters are designed to be informative and educational in nature, and often include links to CMS citations and resources. The newsletter archive is available here and is also included in the ChargeAssist® Document Center. In addition to specific reports, this page provides several links to indices which allow you to search current and previous newsletters by common keywords, phrases, and claims review findings. To learn more about the CERT Program and access CERT related resources, see the following websites:

Integrating CERT into Compliance Programs

Every hospital realizes that effective compliance programs require a proactive auditing strategy. We suggest that CDM, compliance, and internal audit teams incorporate CERT reports and Medicare Quarterly Compliance Newsletters into their compliance monitoring and educational programs. Staff from applicable departments should work as a team to evaluate the report sections and develop an internal action plan. In addition to tracking and monitoring CERT audit notifications, it is also beneficial to review broader categories of CERT audit issues. Identify claim types, services/items, provider types and departments that are impacted by audits. Your specific work plan topics and audit protocol can be set up in ChargeAssist® (or other auditing tools) through special grids, filters, and within the Document Center. These auditing methods will keep your hospital organized and proactive. We hope this post will serve as an effective introduction to CERT audits. Providers are encouraged to identify resources that can be used to develop and refine auditing and monitoring plans. Integrating CERT issues into your organization’s internal compliance programs will help reduce risk, and may avoid costly and time-consuming audit defense.

Exhibit A Table 8: Projected Improper Payments (in Billions of Dollars) by Type of Error and Clinical Setting (Unadjusted) (from CMS 2011 CERT Audit Report)

Exhibit B

Centers for Medicare & Medicaid Services Comprehensive Error Rate Testing (CERT) The Centers for Medicare & Medicaid Services (CMS) implemented the Comprehensive Error Rate Testing (CERT) program to measure improper payments in the Medicare fee-for-service (FFS) program.CERT is designed to comply with the Improper Payments Elimination and Recovery Act of 2010 (IPERA); Public Law 111-204). The Department of Health and Human Services (HHS) Office of Inspector General (OIG) estimated the Medicare FFS error rate from 1996 through 2002. The OIG designed its sampling method to estimate a national Medicare FFS paid claims error rate. Due to the sample size – approximately 6,000 claims – the OIG was unable to produce error rates by contractor type, specific contractor, service type, or provider type. Following recommendations from the OIG, the sample size was increased for the CERT program when CMS began producing the Medicare FFS error rate for the November 2003 Report. This methodology includes

  • CERT randomly selecting a sample of approximately 50,000 claims submitted to Carriers, FIs, and MACs during each reporting period.
  • Requesting medical records from the health care providers that submitted the claims in the sample.
  • Where medical records were submitted by the provider, reviewing the claims in the sample and the associated medical records to see if the claims complied with Medicare coverage, coding, and billing rules, and, if not, assigning errors to the claims.
  • Where medical records were not submitted by the provider, classifying the case as a no documentation claim and counting it as an error.
  • Sending providers overpayment letters/notices or making adjustments for claims that were overpaid or underpaid.

The CERT program cannot be considered a measure of fraud. Since the CERT program uses random samples to select claims, reviewers are often unable to see provider billing patterns that indicate potential fraud when making payment determinations. The CERT program does not, and cannot, label a claim fraudulent. Source: http://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/CERT/index.html?redirect=/cert/ Copyright © 2017 Holliday & Associates

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