What does CERT mean in MATHEMATICS

Comprehensive Error Rate Testing (CERT) is a program designed to measure and assess the accuracy of Medicare claim payments made by contractors. It tests a statistically valid sample of claims to identify improper payments and assess financial accuracy in the Medicare fee-for-service program.

CERT measures the accuracy in payment for services rendered, with particular focus on improper payments. This program tests where errors are occurring - whether it is stemming from coding, documentation, billing or any other factor - in order to adjust and improve payment accuracy for all Medicare fee-for-service beneficiaries.

CERT reviews medical records and claims data submitted by healthcare providers for compliance with Medicare coverage, coding and billing rules. A statistically valid sample of claims from each Contractor is randomly drawn over a certain time period and reviewed against the established rules. The sampled claims are then compared to either other sampled claims or to medical records that are also reviewed for correct payment determination.

An independent medical review contractor performs the CERT reviews on behalf of CMS. These individuals must all be board certified physicians or non-physician practitioners currently licensed. They must also successfully complete training prior to performing any reviews.

The documents identified typically include but are not limited to all pertinent records related to treatment given; patient's relevant demographic information such as age, gender; dates spanning from when services were provided through when bill was paid; provider/supplier information including name, type of organization, address; diagnosis codes assigned by either provider or Medicare contractor; procedure codes assigned by either provider or Medicare contractor; diagnosis related group assignments; explanation of service performed including reasons why certain treatments were chosen, disposition of cases and results achieved; enrollee's underlying condition related to service rendered; proof that service provided was medically necessary and reasonable according to generally accepted standards of practice

An improper payment occurs when there is an incorrect decision about whether items or services should have been covered under Medicare laws due to misapplication of those guidelines, including lack of documentation that item/service was medically necessary under applicable coverage rules. In addition, if a claim should have been denied but instead was paid incorrectly with insufficient documentation -- this too would be considered an improper payment under CERT’s guidelines.

Results will vary depending on the test being conducted but typically range from six months up to one year from when samples were selected until being sent back with final results published in annual reports posted online by CMS every October 1st.