CERT Alert - WPS Commitment to Error Rate Reductions
The Centers for Medicare & Medicaid Services (CMS) has established two programs to monitor the accuracy of payments made in the Medicare Fee-for-Service (FFS) program: the Comprehensive Error Rate Testing (CERT) program and the Hospital Payment Monitoring Program (HPMP). The national paid claims error rate is a combination of error rates calculated by the CERT program and HPMP.
CMS requires contractors to implement aggressive efforts to lower these error rates by developing plans that address the cause of the errors, the steps they are taking to fix the problems, and other recommendations that will ultimately lower the error rates. CMS' expectation is that by November 2009, 90% of Medicare claims will be processed by contractors with an error rate less than or equal to the national error rate for November 2008, which was reported as 3.6% in a CMS press release dated November 17, 2008.
As the Medicare contractor in this jurisdiction, it is our responsibility to ensure that Medicare claims are submitted and processed correctly. Through close monitoring, we have identified the following areas of concern for Part A.
- Skilled Nursing Home Facility (SNF) Issues
- Documentation must support the RUG level billed. RUG levels are being recoded because documentation is insufficient to support lookback periods.
- Billing Rehabilitation plus Extensive Services RUG's: documentation submitted must be sufficient to support the extensive services billed
- Billing Rehabilitation RUG's: documentation must be sent to support all therapy billed
- If you are unsure of what documentation is required refer to the Resident Assessment Instrument (RAI) Manual or your facilities Minimum Data Set (MDS) Coordinator.
- Diagnostic Service Issues
- Missing signed physician order or progress note showing intent for performance of diagnostic services (ex. laboratory, radiology services)
- Therapy Issues
- Missing physician referral and treatment plan for therapy services
What Should You Do If You Receive a CERT Error?
It is crucial that providers in our jurisdictions comply with CERT requests for medical records in a timely manner and submit documentation that supports all services billed to Medicare, including the level of care and medical necessity. We encourage all providers to perform a self-audit on your medical record documentation to ensure completeness. We also encourage you to examine your billing practices. If you utilize a billing service, we recommend sharing educational information to assist with the preparation and submission of your Medicare claims.
To request additional education or to submit questions regarding your specific CERT findings, please e-mail us at Medicare.CERT.Part.A@wpsic.com. Be sure to indicate "CERT Question" in the subject line. Please also include your full name, address, telephone number, and the Medicare Provider Number (if available) in the body of the e-mail. This will assure a prompt reply to your question.
When e-mailing WPS Medicare, please do not include sensitive information. If your question pertains to a specific claim, include the Internal Control Number, not your patient's Medicare Health Insurance Claim Number.
To review the latest CMS CERT Reports, please visit the CMS CERT Website 
.
WPS Medicare Websites:
WPS Medicare Home Page
WPS Medicare CERT Web Page
Page Last Updated: Thursday, 18-Mar-2010 05:48:34 CDT
