Comprehensive Error Rate Testing (CERT)
In order to improve the processing and medical decision making involved with payment of Medicare claims, the Centers for Medicare & Medicaid Services (CMS) designed the Comprehensive Error Rate Testing (CERT) program. The CERT program determines the underlying reasons for errors in claims payments or denials, and implements appropriate corrective actions aimed toward improvements in the accuracy of claims and systems of claims processing.
The CERT Documentation Contractor (CDC) will request medical records for all services billed on the sampled claim. The CDC will send up to four requests with a final deadline of 75 days after the initial request. It is Wisconsin Physicians Service (WPS) Medicare's responsibility to monitor the timeliness and accuracy of responses to these requests for providers in our jurisdiction. If you submit claims to WPS Medicare Part A, and fail to respond to the CERT request, you may be contacted by our CERT Nurse Analyst in order to obtain the documentation.
Upon receipt of the medical record documentation, the CERT Review Contractor (CRC) will begin the review process to determine if the claim was paid correctly or if further documentation is needed. To notify providers of the need for further documentation a letter will be sent stating specifically what documentation is missing. Providers have an additional 14 days to submit documentation before an error is assessed and the billed dollars are subject to overpayment collection.
When an error has been assessed, WPS providers may receive a phone call from the CERT Nurse Analyst to verify if additional documentation is available. To overturn an error, the missing documentation must be submitted to the CRC for re-review. When the review is complete, WPS Medicare Part A will be notified if there is a revised decision. If the CERT reviewer has determined that the records now adequately document the service(s) billed, WPS Medicare will process an adjustment for the additional payment.
Important Facts:
- HIPAA does not prevent providers from sending requested documentation. When a beneficiary enrolls with Medicare, permission has been given for claims to be reviewed.
- At no time during the request process will the CDC, CRC or WPS pay for the cost of medical records documents' duplication or mailing. If using a copy service ensure that it does not bill the CDC, CRC, or WPS.
- Providers can submit correct address and phone numbers at:
http://www.certcdc.com/certproviderportal/
- Documentation to support each line billed must be submitted within the specified time frame. Refer to documentation guidelines at http://www.wpsmedicare.com/
- The WPS Medicare Part A CERT Nurse Analyst is Erin Johnson, RN/BSN Phone (402) 351-5876 or e-mail Erin.Johnson@wpsic.com
Page Last Updated: Wednesday, 17-Feb-2010 14:35:41 CST
