Fast facts: Education on CERT error
The Comprehensive Error Rate Testing (CERT) review contractor (RC) randomly selects a statistically valid sample of Medicare fee-for-service (FFS) claims and reviews those claims for payment errors. The CERT program considers any payment that should not have been made or that was paid at an incorrect amount (including overpayments and underpayments) to be an improper payment.
When the review is complete, the CERT RC will assign the claim a status of no error or error.
- No error means the claim was billed and paid properly and no further action is needed
- Error means the CERT RC found something wrong during their review
Common error categories include:
- Insufficient documentation
- Incorrect coding
- Medically unnecessary service or treatment
- No response to the documentation request
When the CERT RC assigns an error, First Coast will begin processing the claim adjustment for both overpayments and underpayments, if applicable.
First Coast has a CERT team which includes Targeted Education Specialists (TES) to supplement the provider education already available to specifically address CERT errors with providers.
The TES team completes outreach through telephone calls, email, and various other correspondence to conduct one-on-one targeted provider education on claim-specific CERT errors, submission of additional documentation, Medicare regulations and appeals.
The TES also functions as a liaison for providers, communicating review findings, answering claim related questions, assisting with appeals, and obtaining missing documentation with the goal of decreasing the Medicare fee-for-service improper payment rate.
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