BC Advantage - 2023 Issue 7
The CERT Program: What It Is and What a Practice Needs to Know
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Article Overview
This article explains the Medicare Comprehensive Error Rate Testing (CERT) program and why it matters to practices that bill Medicare fee-for-service claims. It covers the program’s purpose, how claims are selected and reviewed, common categories of improper payment findings, what a practice should do when a CERT records request arrives, and how the annual CERT report can support compliance efforts. The content is relevant to billing, compliance, auditing, and practice management staff who need to understand Medicare oversight and response procedures.
Why This Topic Matters
CERT findings can affect payment integrity, documentation practices, and a practice’s overall Medicare compliance posture. Understanding the program helps practices prepare for records requests, respond appropriately, and use published data to target internal education and process improvements.
Article Sections
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What Is the CERT Program?
Introduces the Medicare CERT program, its role in payment integrity, and its oversight and reporting context. It also explains the historical background and general purpose of the program.
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How Does the CERT Program Work?
Describes the claim review process, sampling approach, and broad categories of findings associated with Medicare payment errors. It also summarizes how annual program reporting presents results at a high level.
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Why Is the CERT Program Important?
Explains the broader value of CERT data for Medicare oversight, research, and compliance monitoring. It also discusses the relationship between CERT reporting and follow-up actions by Medicare contractors.
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What to Do if a Records Request Arrives at a Practice
Covers practice response preparation, records-request handling, and the general appeals and follow-up process after a CERT audit. It emphasizes workflow planning, documentation handling, and external support considerations.
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How the CERT Report Can Be Used to Keep a Practice Compliant
Discusses how practices can use annual CERT reporting to identify risk areas and monitor internal compliance efforts. The section focuses on using published trend information for education and process improvement.
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In Conclusion
Summarizes the article’s main themes about the CERT program, records requests, and compliance readiness.
What You Will Learn
- What the Medicare CERT program is and why it exists
- How CERT reviews claims and reports improper payment findings
- What kinds of practice response steps are discussed for a CERT records request
- How annual CERT reporting can inform compliance efforts
- Which organizations and Medicare contractors are involved in the process
Who Should Read This
- Medical practices
- Billing staff
- Coders
- Auditors
- Compliance staff
- Practice managers
- Healthcare consultants
- Healthcare attorneys
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