CERT Audits – Need-To-Know Information

The Centers for Medicare & Medicaid Services (CMS) began resuming the Comprehensive Error Rate Testing (CERT) program on August 11, 2020, after a temporary suspension due to the public health emergency from the COVID-19 pandemic.

Durable Medical Equipment (DME) suppliers and providers should be ready for the CERT contractor audit this year. The CERT program selects providers and suppliers to audit through random selection. 

CERT Program Details  

The CERT program has begun sending documentation request letters and calling providers or suppliers regarding claims review.

If You Are Contacted

If the CERT Program contacts you, you will need to provide the requested medical documents and send them to the CERT Documentation Center within 45 calendar days of the request. 

Contact the CERT Documentation Center Customer Service to request an extension or with additional questions. 

Reporting Years 

The Reporting Years (RY) for 2021 include claims submitted 7/1/2019 through 6/30/2020. The RY for 2022 include claims submitted 7/1/2020 through 6/30/2021. 

CMS altered the CERT program activities and ceased provider contact for RY 2020 claims. Additionally, CMS will reduce the sample size for RY 2021 and RY 2022 to account for provider’s and suppliers’ challenges during the public health emergency.  

Appealing Decisions

Anyone listed on the CERT determination letter can appeal the Medicare coverage and payment decision. It can include beneficiaries, providers, suppliers, and any appointed representatives. 

Learn More

To learn more in-depth details about the CERT program, visit their website.  

About CERT

To calculate improper payment rates for the Medicare Fee-for-Service (FFS) program, CMS developed the CERT program. This program reviews paid claims that appear to have been improper payments. Improper claims can include the paid amount was over or underpaid or that the claim should have been denied.

How the Program Works

Randomly chosen claims are from a stratified random sample of Medicare FFS claims. When the claims are selected, the supporting documents are sent from the provider or supplier and reviewed by independent medical reviewers. 

If there are no document errors, the claim is clean, and no other action is needed.

If there are document errors, the claim is marked as a total or partial improper payment.

Improper payments could happen because of:

  • No documentation 
  • Insufficient documentation
  • Medical necessity 
  • Incorrect coding 
  • Other reasons not included in the above categories 

Types of Contractors

If you are requested to provide information for a CERT audit, you may work with the two contractors. The CERT Review Contractor requests the needed documentation, reviews the data, and other similar responsibilities. The CERT Statistical Contractor calculates improper payment amounts and rates and designs the sampling strategy.

Medbill Can Help

Medbill is a high-skilled and trained team that can help you become audit ready before receiving the document request letter. As a DME billing company that’s 100% U.S.-based, we can help you prepare for the different types of audits that may occur. 

Contact the Medbill team today!