Error Rate Testing Contractors (CERTs)
CERTs calculate and monitor the accuracy of Medicare fee-for-service
(FFS) claims submitted to MACs, carriers and DME regional carriers, to gain insights
into the causes for errors. Each year, CERTs evaluate a statistically valid
random sample of claims to determine if they were paid properly under Medicare
coverage, coding, and billing rules. Claims selected for CERT review are
subject to potential post payment denials, payment adjustments, or other
administrative or legal actions, depending on the result of the review. CMS
publishes the results of these reviews annually.
There are three types of CERTs: the CERT Review Contractor (RC), the
CERT Documentation Contractor (DC), and the CERT Statistical Contractor
(SC). The current DC is Livanta LLC., responsible for
reviewing selected claims and associated medical record documentation. The
current RC is NCI
AdvanceMed Corp., responsible for requesting and receiving the medical
record documentation from providers. The current SC is The Lewin Group, responsible for
randomly selecting a statistically valid sampled claim.
When CERTs request provider documentation for services billed, the
provider must respond within 45 calendar days from the request. Providers also
are required to respond to all requests for additional information within the
time-frame outlined in a request letter. CERTs focus on the following five error
Providers have the same appeal rights under the CERT program as they
would have under traditional Medicare. For more information, you can visit the
CMS site here.