Comprehensive Error Rate Testing (CERT)

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Effective August 11, 2020, the Centers for Medicare & Medicaid Services (CMS) resumed Comprehensive Error Rate Testing (CERT) program activities that were temporarily suspended in response to the public health emergency (PHE) for the 2019-Novel Coronavirus (COVID-19) pandemic.

Due to the cyclical nature of the CERT program improper payment measurement and the statutory timeline required for improper payment reporting under the Payment Integrity Information Act of 2019 (PIIA) (i.e., reporting annually), improper payment measurements cannot pause for an extended period without missing the statutorily required due dates.  

CMS adjusted CERT program data collection by reducing the sample size for Reporting Year (RY) 2021 and RY 2022 to account for the challenges incurred by providers and suppliers during the PHE, while continuing to maintain appropriate accountability measures and meet statutory obligations.

If a provider or supplier receives a CERT documentation request, the provider or supplier should send the requested documentation to:

              CERT Documentation Center
              1510 East Parham Road
              Henrico, VA 23228
              Fax: 804-261-8100

Should a provider or supplier have questions on the documentation request or prefer the request to be made in a format other than a postal mailing, the CERT Documentation Center Customer Service may be contacted via:

             Phone: 1-888-779-7477
             Email: CERTprovider@nciinc.com

The CERT documentation requests identify that the requested documents are to be submitted within 45 calendar days of the request. However, the CERT program has the discretion to grant extensions to providers and suppliers who need more time to comply with the request. Providers and suppliers  should contact the CERT Documentation Center Customer Service to identify any hardships or additional time needed with responding to a CERT documentation request.

We believe that this guidance is a statement of agency policy not subject to the notice and comment requirements of the Administrative Procedure Act (APA).  5 U.S.C. § 553(b)(A).  For the same reasons explained above, the CMS additionally finds that, even if this guidance were subject to the public participation provisions of the APA, prior notice and comment for this guidance is impracticable, and there is good cause to issue this guidance without prior public comment and without a delayed effective date.  5 U.S.C. § 553(b)(B) & (d)(3).

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The Centers for Medicare & Medicaid Services (CMS) estimates the Medicare Fee-for-Service (FFS) program improper payment rate through the Comprehensive Error Rate Testing (CERT) program. Each year, the CERT program reviews a statistically valid stratified random sample of Medicare FFS claims to determine if they were paid properly under Medicare coverage, coding, and payment rules.

The fiscal year (FY) 2020 Medicare FFS estimated improper payment rate is 6.27 percent, representing $25.74 billion in improper payments, compared to the FY 2019 estimated improper payment rate of 7.25 percent representing $28.91 billion in improper payments (1). The table below outlines the improper payment rate and projected improper payment amount by claim type for FY 2020. The reporting period for this improper payment rate is July 1, 2018 through June 30, 2019.

Claim Type

Improper Payment Rate

Improper Payment Amount (2)

Overall

6.27%

$25.74 B

Part A Providers (excluding Hospital Inpatient Prospective Payment System (IPPS))

6.15%

$10.92 B

Part B Providers

8.09%

$8.44 B

Hospital IPPS

3.00%

$3.61 B

Durable Medical Equipment, Prosthetics, Orthotics, and Supplies

31.80%

$2.77 B

All public reports produced by the CERT program are available through the "CERT Reports" link on the left navigation. The improper payment rate is released annually in the Department of Health and Human Services (HHS) Agency Financial Report (AFR), which can be accessed through the HHS AFR link in the Related Links section at the bottom of this page.

(1) The national overall and hospital IPPS improper payment rates are adjusted for the impact of Part A to B rebilling of denied inpatient claims.  

(2) Columns may not sum correctly due to rounding.

Improper Payment Rates and Additional Data

National CERT Improper Payment Rate by Reporting Year

Reporting Year1

Total Expenditures (B)

Improper Payment Rate2

95% Improper Payment Rate Confidence Interval

Improper Payment Amount (B)

2012

$349.7

8.5%

8.1% - 8.9%

$29.6

2013

$357.4

10.1%

9.5% - 10.7%

$36.0

2014

$360.2

12.7%

11.9% - 13.5%

$45.8

2015

$358.35

12.09%

11.4% - 12.7%

$43.33

2016

$373.65

11.00%

10.2% - 11.8%

$41.08

2017

$380.76

9.51%

8.9% - 10.1%

$36.21

2018

$389.30

8.12%

7.6% - 8.6%

$31.62

2019

$398.62

7.25%

6.9% - 7.6%

$28.91

2020

$410.81

6.27%

5.8% - 6.7%

$25.74

1 Each reporting year contains claims submitted July 1 two years before the report through June 30 one year before the report. For example, reporting year 2019 contains claims submitted July 1, 2017 through June 30, 2018.

2 Adjusted for A/B rebilling

Page Last Modified:
06/08/2021 04:46 PM