The Government Performance and Results Act of 1993 sets performance measurement standards for federal agencies. To achieve the goals of this Act for the Medicare Program, CMS established the Comprehensive Error Rate Testing (CERT) program in 2000. CERT's aim is to measure and improve the quality and accuracy of Medicare claims submission, processing and payment. Previously, the Office of the Inspector General (OIG) calculated an annual national error rate using a relatively small sample of claims (about 6000). Now, under the CERT program literally hundreds of thousands of claims are re-reviewed each year. This results in a much more accurate and detailed picture.

The company CMS hired to execute CERT is AdvanceMed (formerly DynCorp), and is known as the CERT PSC (Program Safeguard Contractor). AdvanceMed regularly selects random claims from Medicare contractors, requests records directly from provider, then uses highly standardized and reliable review criteria to determine claims accuracy. AdvanceMed's medical review staff has access to national and local policies, contractor processing guidelines and automated edits. AdvanceMed's medical review staff includes clinicians such as nurses and physicians, who can use clinical judgment when necessary in reviewing medical records. Elements of the review include, but are not limited to, verifying that: 1) providers are coding and submitting claims properly; 2) the local contractor is paying only for covered, medically necessary and adequately documented services; 3) the local contractor appropriately applies relevant policies and procedures.

The results of CERT reviews are used to characterize and quantify local, regional and national error rate patterns. CMS then can use this information to develop appropriate educational and interventional programs to reduce errors. The following specific types of error rates are calculated for individual contractors and are also broken down by provider and service type:

• Paid Claims Error Rate = Dollars overpaid - Dollars underpaid / Total dollars allowed.
• Services Processed Error Rate = Number of services overpaid + Number of services underpaid / Total number of services processed.
• Provider Compliance Error Rate = Dollars submitted incorrectly / Total dollars submitted
  

The present goal is to reduce payment error to below 4 percent by 2008. The current (2003) national paid claims error rate is just under 6%.

A significant percentage (40-50%) of the overall error rate is actually due to providers not sending requested supporting documentation to AdvanceMed. Therefore, if you receive a letter from AdvanceMed, you must respond immediately by submitting the requested supporting documentation as directed within the time frame outlined in the request. Include any records that you believe supports the service(s) billed to the Medicare program. If you fail to submit this information in a timely fashion, an "error" is registered against both the contractor (GHI Medicare) and the provider. You will also receive a demand letter requesting refund of payment received for the "erroneous" claim. Therefore we strongly encourage you to be aware and advise your staff that a letter from AdvanceMed/CERT requesting medical records must receive prompt and deliberate attention.

Forwarding specifically requested records to AdvanceMed does not violate HIPAA privacy statutes. Medicare beneficiaries have consented to the release of medical information necessary to process their Medicare claims. AdvanceMed, as part of the Medicare claims payment system is legally authorized to request and review these records. Providers do not need to obtain additional beneficiary authorization to forward medical records to AdvanceMed. (Please note that Medicare does not issue separate reimbursement for the cost of copying records. This is considered an administrative fee that has already been built into the amount paid for services allowed by Medicare.)

If CERT changes the payment decision on your claim by denying or reducing payment you can still file an appeal with the contractor (GHI Medicare), as with any other claim. Providers who disagree with any denial or reduction are encouraged to file appeals. Appeal reversals will be backed out of the error rate computations. Do not send appeal requests to AdvanceMed, only medical records when specifically requested. All appeals should be submitted through the local contractor's (GHI Medicare's) standard appeal mechanism.

You can learn more about the CERT program on the CMS CERT page. The final letter concludes as follows:

"Failure to send the requested information may also result in a referral to the Medicare contractor fraud unit and to the Office of Inspector General (OIG) which may exclude from participation in the Medicare and Medicaid individuals and entities which fail to supply payment information which the Department of Health and Human Services finds necessary to determine whether payments are or were due and the amounts thereof. Section 1128(b)(11) of the Social Security Act, 42 U.S.C. § 1320a-7(b)(11)."

Please adhere to the following directions when photocopying, packaging, and mailing the requested records:

1. Complete and attach the CERT Contractor barcoded cover sheet for each record.
2. Fax the barcoded coversheet and medical record to the CERT Contractor at: (804) 264-3268 or (804) 864-9980
3. If you do not have the barcoded sheet, please write the CID number on the front page of the medical record before faxing or mailing to the CERT Contractor.
4. If the medical record is too long to fax, or you would rather mail it, you may send it to:
   
   AdvanceMed
   CERT Operations Center
   Attn: Disposition Department - Distribution
   1530 E. Parham Road
   Richmond, VA 23228
   
   
5. If you would like to verify if CERT received your medical documentation, please contact the AdvanceMed CERT Customer Service line at (804) 864-9940 or (804) 264-1778.