Comprehensive Error Rate Testing (CERT)

******************************************************************************************************************

Effective August 11, 2020, the Centers for Medicare & Medicaid Services (CMS) is resuming 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. Specifically, the CERT program will resume sending documentation request letters to and conducting phone calls with providers or suppliers to request medical documentation for claims in Reporting Year (RY) 2021 (claims submitted 7/1/2019 through 6/30/2020) and RY 2022 (claims submitted 7/1/2020 through 6/30/2021).  

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.  

The CERT program will not resume sending documentation request letters to, or conducting phone calls with, providers or suppliers to request medical documentation for claims in RY 2020 (claims submitted 7/1/2018 through 6/30/2019). The CERT program will report the 2020 Medicare Fee-for-Service (FFS) program improper payment rate in the November 2020 Department of Health and Human Service (HHS) Agency Financial Report (AFR) based on the data that CMS currently has or that providers or suppliers voluntarily submit.

CMS has altered CERT program activities in the short term (i.e., ceasing provider contact for RY 2020 claims) and adjusted data collection in the longer term (i.e., sample size reduction for RY 2021 and RY 2022 claims) 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 RY 2021 or RY 2022 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. CMS will continually evaluate the CERT program activities to gauge whether any future suspension might again become necessary.Based on the cutoff dates for annual improper payment reporting, providers and suppliers will have until August 2021 to submit documentation on claims in the RY 2021 report period and August 2022 to submit documentation on claims in the RY 2022 report period.

A CERT determination can be appealed. Any party to the CERT determination, such as beneficiaries, providers, and suppliers – or their respective appointed representatives – has the right to appeal the Medicare coverage and payment decision.

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).

******************************************************************************************************************

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) 2019 Medicare FFS estimated improper payment rate is 7.25 percent, representing $28.91 billion in improper payments, compared to the FY 2018 estimated improper payment rate of 8.12 percent representing $31.62 billion in improper payments (1). The table below outlines the improper payment rate and projected improper payment amount by claim type for FY 2019. The reporting period for this improper payment rate is July 1, 2017 through June 30, 2018.

Claim Type

Improper Payment Rate

Improper Payment Amount (2)

Overall

7.25%

$28.91 B

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

8.07%

$13.34 B

Part B Providers

8.64%

$8.66 B

Hospital IPPS

3.57%

$4.47 B

Durable Medical Equipment, Prosthetics, Orthotics, and Supplies

30.70%

$2.44 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.

 

 

 

Page Last Modified:
08/11/2020 09:02 AM