Avoid Denials and Mitigate Risk Under the CMS CERT Program

Why This Topic Matters

Understanding CERT helps healthcare organizations reduce documentation-related claim problems, respond appropriately to record requests, and monitor areas of higher Medicare review risk. It also supports compliance efforts by highlighting the broader relationship between documentation quality, coverage review, and improper payment reporting.

Article Sections

1. CERT program overview and record requests

   Introduces the CMS CERT process, the role of medical record documentation requests, and the general review framework used for Medicare claims.

2. Error categories and documentation issues

   Summarizes the major CERT error categories and the broad types of documentation problems commonly associated with claim review findings.

3. Services under special CMS scrutiny

   Identifies selected service areas that CMS tracks closely because of documentation or medical-necessity concerns.

4. FY2016 Medicare fee-for-service payment results

   Provides a high-level look at reported improper payment rates, recovery results, and related Medicare program statistics for the fiscal year discussed.

5. Fraud, improper payments, and follow-up review

   Explains the relationship CMS draws between improper payments, fraud indicators, and additional review activity.