Overview

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.All public reports produced by the CERT program are available through the "CERT Reports" link on the section navigation tray to the left.

Downloads
CERT 101 Presentation [PDF, 623 KB] Overview of Improper Payment Reviews [PDF, 276 KB] Electronic Submission of Medical Documentation (ESMD) Introduction [PDF, 929 KB]
Related Links Inside CMS
Medicare Claim Review Programs: MR, NCCI Edits,  MUEs , CERT and Recovery Audit Program CMS Fact Sheets CMS Press Releases Press Release - NEW STANDARDS HELPING LOWER MEDICARE IMPROPER PAYMENT RATES FOR 2010   Press Release - HHS EMPLOYS NEW TOUGHER STANDARDS IN CALCULATION OF IMPROPER MEDICARE PAYMENT RATES FOR 2009 Press Release - CMS ISSUES IMPROPER PAYMENT RATES FOR MEDICARE, MEDICAID, AND SCHIP   Press Release - MEDICARE CONTINUES TO REDUCE IMPROPER CLAIMS PAYMENTS    Press Release - MEDICARE REDUCES IMPROPER CLAIMS PAYMENTS BY HALF   Press Release - CMS ANNOUNCES IMPROVED EFFORTS TO REDUCE MEDICARE PAYMENT ERROR RATES
Related Links Outside CMS
Payment Accuracy FY 2010 Agency Financial Report Improper Payments Elimination and Recovery Act of 2010 Improper Payments Information Act of 2002 CMS on Twitter

Page Last Modified: 12/20/2011 4:54:16 PM
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