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Claims Error Rate More Than Doubles

April 6, 2010:

The most recently published Comprehensive Error Rate Testing (CERT) report dated November 2009 indicates a paid claims error rate of 7.8 percent; the error rate for the previous year was 3.6 percent. The increase may be the result of significant revisions in the methods the Centers for Medicare and Medicaid Services (CMS) uses to identify and calculate paid claim error rates. It should be noted that due to these revisions, results from previous-year CERT reports cannot be directly compared with the 2009 report.

A significant portion of the new errors found in fiscal 2009 were due to a strict adherence to policy documentation requirements, signature legibility requirements, the removal of claims history as a valid source for review information, and the determination that medical record documentation received only from a supplier is, by definition, insufficient to substantiate a claim.

CERT is one of two programs that CMS established to monitor and report the accuracy of Medicare fee-for-service payments. The CERT methodology includes:

  • Selecting a random sample of approximately 120,000 submitted claims
  • Requesting medical records from providers who submitted the claims
  • Reviewing the claims and medical records for compliance with Medicare coverage, coding, and billing rules

The CERT program was developed as a means of establishing a national, contractor-specific and benefit-category-specific paid claims error rate. Beginning in 2003, CMS elected to calculate a provider compliance error rate in addition to the paid claims error rate. The provider compliance error rate measures how well providers apply coding and billing conventions as well as assessing the efforts of contractor education regarding errors. The CERT provider error rate can also help focus an internal audit.

Under the CERT program, independent reviewers examine random samples of claims as they are accepted into carrier and intermediary claims processing systems and follow them through the system. The decisions of the independent reviewers are then entered into a tracking database, which allows CMS to identify trends as they arise. CERT is also used to identify where corrective action may be needed and to monitor and direct the performance of contractors. In addition, the large volume of claims in the database that have undergone independent review can be used to test new software.

As a result of CERT, contractors are no longer required to conduct random prepayment medical reviews.

The Physician Compliance Guide has more detailed information regarding the CERT program and previous-year CERT reports.


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