Medical Review/Comprehensive Error Rate Testing (CERT)
Welcome to the WPS Medicare Medical Review/Comprehensive Error Rate Testing (CERT) Web page.
The Centers for Medicare & Medicaid Services (CMS) states the following regarding Medical Review (MR):
The goal of the medical review program is to reduce payment error by identifying and addressing billing errors concerning coverage and coding made by providers. To achieve the goal of the MR program, contractors:
- Proactively identify potential billing errors concerning coverage & coding made by providers through analysis of data (e.g., profiling of providers, services, or beneficiary utilization) and evaluation of other information (e.g., complaints, enrollment and/or cost report data);
- Take action to prevent and/or address the identified error. Errors identified will represent a continuum of intent, and;
- Publish local medical review policy to provide guidance to the public and medical community about when items and services will be eligible for payment under the Medicare statute.
Closely related to MR is the Comprehensive Error Rate Testing (CERT) program. According to CMS the CERT program:
… Established two programs to monitor and report the accuracy of Medicare Fee For Service (FFS) payments: The Comprehensive Error Rate Testing (CERT) program and the Hospital Payment Monitoring Program (HPMP). The national error rate is calculated using a combination of data from the CERT contractor and HPMP with each component representing about 60% and 40% of the total Medicare FFS dollars paid, respectively. The CERT program measures the error rate for claims submitted to Carriers, Medicare Administrative Contractors (MACs), Durable Medical Equipment Medicare Administrative Contractors (DME MACs) and Fiscal Intermediaries (FIs). The HPMP measures the error rate for the Quality Improvement Organizations (QIOs).
Annually, CMS monitors the accuracy of Medicare Fee-For-Service (FFS) payments. CMS contractors use the Comprehensive Error Rate Testing (CERT) program information to determine which services are experiencing high error rates. They then perform comprehensive data analysis to identify specific providers for MR probe review. In a probe review, a contractor samples a small number of claims from a given provider for a given service and reviews them to determine if the provider is billing in error. When the probe review indicates that corrective action needs to be taken, the contractor may take the corrective action they deem most appropriate.
To learn more about MR and CERT, please use the links in the left-hand navigation bar.
Important Links
