CERT Audit and Investigation Process

CERT (Comprehensive Error Rate Testing) contractors randomly select and review statistically valid samples of Medicare claims to determine the rate of improper payments. First, the CERT randomly selects claims. Then, the CERT sends out medical records requests to physicians and other medical providers. Once the information is received, the CERT reviews the claims for correctness.  After the review of the sample claims is complete, the CERT assigns improper payment rate categories. Finally, the CERT compiles the data and produces the alleged Improper Payment Rate.  This information is then used by MAC’s and other Medicare contractors to assist in identifying improper payments and areas of risk for Medicare fraud. The information gathered by CERT’s is used to improve system edits, update coverage polices and manuals, and conduct provider education efforts.

If a medical provider receives a request for medical records from a CERT, the provider has 75 days to respond to the request. If no documentation is received, the claim is counted as an error. The CERT will review records received after 75 days, but it is advantageous to respond timely. A timely response ensures a medical provider’s claim will not incorrectly be categorized as an error or Medicare fraud.  Improper payment categories used by CERT’s are no documentation, insufficient documentation, lacking medical necessity, incorrect coding, and other.

Claims that are selected for CERT review are subject to the following if an improper payment is discovered: postpayment denials; payment adjustments; and other administrative or legal actions. Normal appeal rights and process are available to physicians and other medical providers that disagree with the CERT determination.  Appeals should be sent/filed to the MAC. The attorneys at Chapman Law Group are familiar with CERT reviews and can work with medical providers to prepare timely responses to medical record requests.  Do not hesitate to call the attorneys at Chapman Law Group if you are engaged in a CERT audit.

Our Experience

Our team of audit attorneys includes a former senior Medicare attorney who worked for the office of Medicare Hearing and Appeals prior to joining the firm. He has extensive experience in Medicare audits, including CERT, ZPIC, RAC, and Safeguard (PSC) audits. He also has extensive experience with overpayment demands, secondary payer recovery, and appeals. Together our team of health care audit attorneys help providers defend their claims during audits, recovery action, and appeals.  We represent providers and practices nationwide during Medicare audits, overpayment demands, and Medicare appeals.

Comparison of Health Care Fraud Statutes and Penalties

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