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 MAC’s 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.

Comprehensive Error Rate Testing Review Claims

Claims that are selected for CERT review are subject to the following if an improper payment is discovered:

    • Postpayment denials
    • Payment adjustments
    • 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. 

Why You Should Choose Chapman Law Group When Your Health Care Practice is Audited

We represent providers and practices nationally during Medicare audits, Medicaid audits and third-party payor audits. Our team of Medicare and Medicaid audit attorneys has extensive experience in Medicare audits, including ZPICRAC, and Safeguard (PSC) audits.

Our offices are in Detroit (where we serve Dearborn, Troy, Ann Arbor and Grand Rapids, and the rest of Michigan); Miami and Sarasota, Florida (for Jacksonville, Tampa, Orlando, West Palm Beach, and all of Florida); Los Angeles/Southern California; and Chicago

Do not hesitate to call the attorneys at Chapman Law Group if you are engaged in a CERT audit. With lawyers dedicated to helping providers defend their claims during audits, recovery action and appeals, you are in strong hands. Contact us today for a consultation.

Need an Attorney? Contact us now!


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