CERT Audits and Investigations
Audits are a regular part of doing business in the healthcare industry, and there are a variety of audits that licensed healthcare professionals may encounter. CERT audits and investigations are one of these, and they are launched by contractors researching improper Medicare payment rates.
With more than a decade in healthcare law, the attorneys at Norman Spencer Law Group have extensive experience helping clients through the process of a CERT audit or investigation. We can help you respond to CERT record requests, appeal CERT determinations and establish an effective compliance plan to ensure all services are documented as required.
What is CERT?
CERT stands for Comprehensive Error Rate Testing, and it is a program used to determine if Medicare claims are being paid properly. This program is used as a tool by the Centers for Medicare and Medicaid Services (CMS) to assess the claims paid by Medicare Administrative Contractors (MAC) to healthcare providers within their region.
If a CERT contractor finds that a MAC has been improperly reimbursing healthcare professionals for claims that may not be eligible for coverage, the MAC takes action to pinpoint the deficiency within the system.
How CERT Audits Work
The goal of CERT contractors to randomly select and review samples of Medicare claims to gauge the rate of incorrect payments. The first step is for contractors to select statistically valid samples of Medicare claims. They then request the medical records connected to those claims from healthcare providers.
CERT contractors then review the claims against the medical records to ensure the claims are correct. After contractors review the sample claims, they assign improper payment rate categories.
In the final phase of the process, CERT contractors compile the data and established the alleged improper payment rate. This data is used by Medicare contractors, such as MAC’s, to help them identify incorrect payments and other issues that may indicate Medicare fraud. The data collected by CERT contractors is used to update coverage policies and manuals, improve system edits and provide additional education to healthcare professionals.
CERT Record Requests
When licensed healthcare professionals receive a CERT request for medical records, they have 75 days to respond. If providers do not send the records within the allotted time frame, the claim is calculated as an error. Although CERT contractors will still review records received after the 75-day timeframe, it is in a provider’s best interests to respond in a timely manner.
Responding in a timely fashion ensures the healthcare professional’s claim will not be erroneously categorized as an error or Medicare fraud. CERTS use a variety of improper payment categories. Some of the most common include:
- No documentation
- Insufficient documentation, which could include lack of a valid physician’s signature or lack of a valid physician’s order for testing or services
- Lacking medical necessity, or procedures not backed up with proper medical documentation
- Incorrect coding, often related to laboratory testing
- Invasive procedures without medical necessity
- Incorrect procedure code, which can arise while billing services
- Billing for services that were not rendered
- Incorrect discharge code
Claims selected for CERT review are chosen randomly, but they may very well contain improper payments. If an improper payment is discovered, the claim can be subject to a variety of actions. These include:
- Post-payment denials
- Payment adjustments
- Other administrative action or legal repercussions
How to Respond to CERT Record Requests
When a healthcare provider receives a record request from CERT, it’s important to remember that their practice is not being accused of wrongdoing or fraud. CERT audits are primarily meant to ferret out mistakes or deficiencies on the part of MAC’s. That doesn’t mean, however, these requests should be taken lightly.
If an overpayment is identified, it’s the healthcare professional that will bear the responsibility, not the MAC. It’s also important to keep in mind that unfavorable results during a CERT audit may result in further auditing down the line.
Healthcare professionals need to carefully review the request, and then take appropriate steps to compile a complete set of medical records and other supporting documents associated with the specific claims in question. Practices that make compliance a daily part of their routine will have a much easier time of it, as their documentation already accurately shows medical necessity and the level of services performed.
Appealing CERT Determinations
Licensed healthcare providers that disagree with CERT determinations have the right to appeal the decision. Appeals need to be filed with MAC and they follow the normal appeal process. The lawyers Norman Spencer Law Group are familiar with CERT reviews. We can work with licensed healthcare professionals to prepare timely responses to requests for medical records. We can also advise on best practices to ensure healthcare providers have an effective compliance plan in place, which makes records requests much less stressful and easier to fulfill. Contact our office to schedule a consultation today.
compliance
Now, more than ever, it is important that you have an effective Compliance Plan in place. Your Compliance Plan should explicitly set out your organization’s policies about how to correctly assess the need for, and document the services provided to a Medicare beneficiary. Otherwise, as demonstrated by the tough stance being taken by the MAC discussed above, CERT audits and other Medicare post-payment audits could raise serious problems for your practice.
Normal appeal rights and process are available to physicians and other medical providers that disagree with the CERT determination. Appeals should be sent/filed to the MAC. The attorneys at Chapman Law Group are familiar with CERT reviews and can work with medical providers to prepare timely responses to medical record requests. Do not hesitate to call the attorneys at Chapman Law Group if you are engaged in a CERT audit.
II. RECENT ACTIONS TAKEN BY MACS IN RESPONSE TO CERT AUDIT FINDINGS
In response to certain CERT audit findings, one MAC recently sent notification to providers of Evaluation and Management (E/M) services explaining that new “stringent corrective actions” will be taken to address some of the more common claims errors identified by the CERT auditors when conducting their reviews of MAC payment practices. As recent correspondence to a provider reflects, MACs are taking the results of CERT audits quite seriously, and are expanding their program integrity efforts. As one MAC recently wrote, the contractor stands ready to:
- Suspend a provider if that provider has “too many” payment errors (it does not state how many is “too many”);
- “[R]efer every physician” to that region’s ZPIC if those providers continue to bill for services which may constitute payment errors;
- “[R]efer every physician” to the ZPIC if there is a pattern of past payment errors; and,
- “[C]onduct prepayment reviews” of future claims, up to 100% of a provider’s claims.
To be clear, none of these potential corrective actions represent new authorities. Nevertheless, the fact that MACs are now reasserting these points is reflective of CMS’ ongoing concerns regarding the prevalence of improper claims. Indirectly, CMS is making it crystal clear that as the initial recipient and screener of Medicare claims submitted by providers for payment, MACs play an essential role in screening out improper claims and bad providers. As Medicare’s primary gatekeepers, MACs are responsible for identifying both improper claims and providers who may be engaged in abusive and / or fraudulent practices.
III. WHAT SHOULD YOU DO IF YOU ARE NOTIFIED OF A CERT AUDIT?
Should you receive a CERT audit request for documents from a CERT Documentation Contractor (CDC), it is important to keep in mind that your practice or clinic is not being accused of fraud or wrongdoing. Fundamentally, a CERT audit is primarily designed to identify deficiencies and mistakes made by Medicare contractors. Nevertheless, it is imperative that you take a CERT audit request quite seriously. At the end of the day, it will be you, not the MAC, who is responsible for any overpayments identified as a result of the audit. Moreover, bad results on a CERT audit may lead to further auditing in the future.
IV. WHAT ACTIONS SHOULD A COMPLIANCE OFFICER TAKE TO AVOID BEING AUDITED?
As an organization, if you are subjected to a CERT audit, the “horse is already out of the barn,” so to speak. Your goal is to review and monitor your organization’s coding, billing and utilization practices on an ongoing basis so that improper claims are never submitted to your MAC in the first place. In most cases, you can check your MAC’s website to determine if their CERT auditor has already identified certain areas of concern. For instance, one MAC recently reported that out of 508 errors identified in a CERT audit of certain Medicare claims, the contractor found that:
- 311 errors were due to “insufficient documentation.” Notably, a majority of the errors in this category were because the medical record “did not contain a valid physician’s signature” or because a diagnostic test performed “did not contain a valid physician’s order” or an identification of the provider who rendered the service.
- 132 errors were due to “lack of medical necessity” based on the medical documentation submitted.
- 37 errors were due to “incorrect coding” (primarily related to laboratory testing).
- 10 errors were due to “invasive procedures that were assessed to be without medically necessity.”
- 9 errors were due to an “incorrect procedure code” used when billing the service.
- 6 errors were the result of “billing for services that were not rendered.”
- 2 errors were due to “other errors.”
- 1 error was due to an “incorrect discharge code being used.”
Compliance Officers can take these “general” risk areas, add them to the “practice-specific” risk areas already noted, and take special note of these concerns when conducting internal reviews. The only way to avoid the scrutiny of Medicare’s various administrative contractors (MACs, ZPICs, RACs and CERT auditors) is to avoid payment errors altogether. While no provider is perfect, the development, implementation and adherence to an effective Compliance Plan can significantly reduce the number of improper claims submitted by a provider to a MAC for reimbursement.
V. WHAT ACTIONS SHOULD A COMPLIANCE OFFICER TAKE AFTER RECEIVING A CERT AUDIT LETTER?
As Compliance Officer, upon receipt of a CERT audit request, you should carefully review the request and take steps to assemble a complete set of medical records and other supporting documentation related to the specific claims at issue. It is important not only to make sure that your documentation is complete when sending in records to a CERT contractor, but to make sure that compliance is a daily part of your practice. Ensuring that your documentation is appropriate and accurately documents both medical necessity and the level of services performed can greatly assist you in avoiding trouble down the road.
Now, more than ever, it is important that you have an effective Compliance Plan in place. Your Compliance Plan should explicitly set out your organization’s policies about how to correctly assess the need for, and document the services provided to a Medicare beneficiary. Otherwise, as demonstrated by the tough stance being taken by the MAC discussed above, CERT audits and other Medicare post-payment audits could raise serious problems for your practice.
As Compliance Officer, upon receipt of a CERT audit request, you should carefully review the request and take steps to assemble a complete set of medical records and other supporting documentation related to the specific claims at issue. It is important not only to make sure that your documentation is complete when sending in records to a CERT contractor, but to make sure that compliance is a daily part of your practice. Ensuring that your documentation is appropriate and accurately documents both medical necessity and the level of services performed can greatly assist you in avoiding trouble down the road.
Now, more than ever, it is important that you have an effective Compliance Plan in place. Your Compliance Plan should explicitly set out your organization’s policies about how to correctly assess the need for, and document the services provided to a Medicare beneficiary. Otherwise, as demonstrated by the tough stance being taken by the MAC discussed above, CERT audits and other Medicare post-payment audits could raise serious problems for your practice.
helping clients with CERT audits and investigations.
The “Comprehensive Error Rate Testing” (CERT) program was created as a tool for the Centers for Medicare and Medicaid Services (CMS) to assess whether Medicare Administrative Contractors (MACs) are paying claims properly.
Essentially, the CERT audit serves as an integral management tool for CMS as well as an important feedback mechanism for the MACs. When problem areas are identified, they can be addressed by Medicare contractors with audit responsibilities. Notably, several of the MACs around the country have been aggressively reasserting their program integrity roles.
Essentially, MACs write reimbursement checks on behalf of CMS. As a result, they play a central role in the Medicare reimbursement process. Therefore, when a CERT auditor finds that a MAC has been incorrectly reimbursing providers for claims which may not qualify for coverage, it is very important that the MAC immediately address this system-wide deficiency.
How CERT Audits Work
This is the point where licensed healthcare providers may receive a notification from MAC alerting them of potential errors in their own claims reimbursements. Responding to such notifications in a timely manner is crucial, and it’s best done with a qualified healthcare law attorney by your side.
The lawyers at Norman Spencer Law Group have extensive experience with all types of Medicare audits, including MAC, RAC, ZPIC and Safeguard.