CMS established the Comprehensive Error Rate Testing (CERT) program to calculate a national paid claims error rate for all of the Medicare Fee-For-Service program. The CERT program calculates the error rates for all Medicare Administrative Contractors (MACs) and, until the transition to MACs is completed, the CERT program will also report on Carriers, and Fiscal Intermediaries (FIs).

The Department of Health and Human Services (DHHS), Office of Inspector General (OIG) produced Medicare FFS error rates from 1996 to 2002. The OIG designed a sampling method that estimated only a national FFS paid claims error rate (the percentage of dollars that Carriers, FIs, and QIOs erroneously allowed to be paid). To better measure the performance of the Carriers, FIs, and MACs as well as to gain insight about the causes of errors, CMS decided to calculate a number of additional rates. The additional rates include provider compliance error rates (which measure how well providers prepared claims for submission) and paid claims error rates (which measure how accurately Carriers, FIs, and MACs made coverage, coding, and other claims payment decisions) for specific contractors, service types, and provider types. CMS began producing error rates and estimates of improper payments for publication in November 2003.

This methodology includes:

• CERT randomly selecting a sample of approximately 100,000 claims submitted to Carriers, FIs, and MACs during each reporting period.
• Requesting medical records from the health care providers that submitted the claims in the sample.
• Where medical records were submitted by the provider, reviewing the claims in the sample and the associated medical records to see if the claims complied with Medicare coverage, coding, and billing rules, and, if not, assigning errors to the claims.
• Where medical records were not submitted by the provider, classifying the case as a no documentation claim and counting it as an error.
• Sending providers overpayment letters/notices or making adjustments for claims that were overpaid or underpaid.

In the November 2009 reporting period CMS changed the way it reviewed inpatient hospital claims for error rate measurement. In the past, inpatient hospital reviews were reviewed under a separate program than other Medicare FFS claims. CMS consolidated the programs and the review procedures for acute inpatient hospital claims are now consistent with the procedures used for review of all other Medicare FFS claims.

The CERT program cannot be considered a measure of fraud. Since the CERT program uses random samples to select claims, reviewers are often unable to see provider billing patterns that indicate potential fraud when making payment determinations. The CERT program does not, and cannot, label a claim fraudulent.

All public reports produced by the CERT program are available through the "CERT Reports" link.on the section navigation tray to the left.

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Page Last Modified: 12/03/2009 10:11:42 AM
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