Comprehensive Error Rate Testing (CERT)

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Pursuant to the Robert T. Stafford Disaster Relief and Emergency Assistance Act, President Trump declared on March 13, 2020 that, as a result of the effects of the Coronavirus Disease 2019 (COVID-19), a national emergency exists nationwide, retroactive to March 1, 2020. On January 31, 2020, Secretary Azar of the Department of Health & Human Services (HHS) declared a nationwide public health emergency, retroactive to January 27, 2020.  Accordingly, the Centers for Medicare & Medicaid Services (CMS) is taking the steps below to allow Medicare providers and suppliers to focus their resources on combating COVID-19. 

Effective immediately, CMS is exercising its enforcement discretion to adopt a temporary policy regarding the Medicare Comprehensive Error Rate Testing (CERT) program under which it will not send documentation request letters to or conduct phone calls with providers or suppliers to request medical documentation until further notice.

Additional guidance regarding the administration of the CERT program will be provided in the coming weeks. Please reach out to the CERT Review Contractor at 1-888-779-7477 if you have any questions.

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) 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:
04/20/2020 08:48 AM