CERT Audit and Investigation Process

Comprehensive Error Rate Testing (CERT) 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 Medicare Administrative Contractors (MACs) and other Medicare contractors to assist in identifying improper payments and areas of risk for Medicare fraud. The information gathered by a CERT 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 CERTs are no documentation, insufficient documentation, lacking medical necessity, incorrect coding, and others.