Provider Types Affected
Medicare Fee-for-Service (FFS) physicians, providers, and suppliers

Provider Action Needed
STOP – Impact to You
The 2004 national gross paid claims error rate was 10.1 percent. A portion of this error rate was a result of providers not sending requested supporting documentation to the designated CERT contractor. Medicare FFS physicians, providers, and suppliers must provide documentation and medical records that support their claims for covered Medicare services to the designated CERT contractor upon request. If you fail to submit documentation, the claim will be considered an error, and you will receive a demand letter requesting refund of payment received for the “erroneous” claim.

CAUTION – What You Need to Know
During a CERT review, you may be asked to provide more information related to a claim you submitted, such as medical records or certificates of medical necessity, so the CERT review contractor (CRC) can verify that billing was proper. Forwarding specifically requested records to the designated CERT contractor does not violate privacy provisions under the Health Insurance Portability and Accountability law.

GO – What You Need to Do
If you receive a letter from CMS with a CERT request for medical documentation, you should respond promptly by submitting the requested supporting documentation within the time frame outlined in the request. Physicians, providers, and suppliers do not need to obtain additional beneficiary authorization to forward medical records to the designated CERT contractor. This special edition article provides an overview of the CERT program and stresses the importance of providing the requested medical documentation for the CERT review.

Background
The Government Performance and Results Act of 1993 established performance measurement standards for federal agencies. To achieve the goals of this act, CMS established the Comprehensive Error Rate Testing program in November 2003. The purpose of the CERT program is to measure and improve the quality and accuracy of Medicare claims submission, processing, and payment. The results of these reviews are used to characterize and quantify local, regional, and national error rate patterns. CMS uses this information to address the error rate through educational and interventional programs.

Methodology
CMS calculates a national paid-claims error rate, a contractor-specific error rate, services-processed error rate (which measures whether the Medicare contractor made appropriate payment decisions on claims), and a provider-compliance error rate (which measures how well providers prepared claims for submission). The CMS methodology includes:
• Randomly selecting a sample of claims submitted in a specific calendar year;
• Requesting medical records from providers who submitted the claims;
• Reviewing the claims and medical records to see if the claims complied with the Medicare coverage, coding, and billing rules; and
• When providers fail to submit the requested documentation, treating the claims as errors and sending the providers overpayment letters.

The CERT review contractor reviews more than 140,000 randomly selected claims and corresponding medical records each year, with a medical review staff that includes physicians and nurses who use clinical judgment when necessary in reviewing medical records. Their medical review staff has access to national and local policies, contractor processing guidelines, and automated edits.

If you fail to submit the requested information in a timely fashion, an "error" is registered against the Medicare contractor (your Medicare carrier or fiscal intermediary) and you, as the Medicare provider. (At this point, the CERT review contractor must register the claim submission as “erroneous” because supporting documentation is insufficient to determine otherwise.) These errors have a corresponding negative impact on the other error rates that are calculated under the CERT program.

Your Role Is Critical to Improvement
CMS research has shown that providers may not comply with the requests for information because they erroneously believe that forwarding specifically requested records to the designated CERT contractor violates HIPAA privacy statutes. It does not; Medicare beneficiaries have consented to the release of medical information necessary to process their Medicare claims. Providers do not need to obtain additional beneficiary authorization to forward medical records to the designated CERT contractor. Physicians also may be unaware of the CERT process and may not appreciate the importance of cooperating in a timely fashion.

If You Receive a Letter from CMS Regarding a CERT Medical Review…
1. Don’t ignore it! Submit the requested supporting documentation within the time frame outlined in the request. The letter will provide a list of the documentation required and where to submit it.
2. Include any additional material that you believe supports the service(s) billed to the Medicare program.
3. Make sure your address and telephone numbers that are on file with your carrier or fiscal intermediary are accurate to ensure that you receive CERT documentation requests and you have time to respond within deadlines.
4. Remember that physicians, providers, and suppliers do not need to obtain additional beneficiary authorization to forward medical records to the designated CERT contractor.

Additional Information
Several resources are available to assist Medicare physicians, providers, and suppliers with CERT compliance:
• CERT Web page (www.cms.hhs.gov/cert)
• CERT Newsletters (www.cms.hhs.gov/cert/letters.asp)
• A telephone number for Medicare physicians, providers, and suppliers for general information and questions regarding the CERT initiative — 804-864-9940.

Disclaimer: This article was prepared by the Centers for Medicare and Medicaid Services’ Medlearn Matters as a service to the public and is not intended to grant rights or impose obligations. This article may contain references or links to statutes, regulations, or other policy materials. The information provided is intended only to be a general summary. It is not intended to take the place of the written law or regulations. We encourage readers to review the specific statutes, regulations, and other interpretive materials for a full and accurate statement of their contents.