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CERT Audit & Investigation Process

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CERT Audit & Investigation Process

CERT is an acronym for Comprehensive Error Rate Testing, which was developed for the purpose of determining if contractors for Medicare paid claims in alignment with requirements. The Centers for Medicare and Medicaid Services, better known as CMS, leverages many tools for the purpose of identifying errors, fraud and overpayment through audits and investigations. The CERT audit and investigation process is quite extensive and provides a lot of feedback that’s valuable to Medicare Administrative Contractors (MACs) as they support the objectives of CMS.

MACs have played an expanded role in writing checks for the purpose of Medicare reimbursement. CERT auditors are intricately involved in the process of making sure reimbursements are accurate and handled appropriately by MACs throughout the Medicare system. In the event that a claim is found to have been reimbursed incorrectly, that issue is addressed throughout Medicare, which usually requires more audits.

Sometimes it’s uncovered that a MAC has inappropriately reimbursed claims that didn’t actually meet the requirements. The reason why CERT audits are important is because the errors found will need to be corrected throughout the Medicare system. For example, CERT audits and investigations have uncovered mistakes in the methods used by MACs to process payments. As a result of this finding, CERT auditors engaged in an extensive number of audits to find out if the problem was widespread; it ended up being quite extensive.

This issues uncovered by CERT auditors resulted in a program that became a masterful undertaking by MACs to address any integrity issues within the system. This ended up having a significant impact on providers because the reimbursement process became more stringent. For instance, it’s a standard practice that providers will be suspended if there are too many payment mistakes. There are a list of rules that aren’t necessarily new, just more diligently followed by MACs.

The bottom line is that CMS is keeping a closer eye out on payments. Some believe it’s because of government budget deficits and a need to decrease costs. At this juncture, the focus is on making sure the mistakes made in the past are no longer occurring. There will continue to be an increased number of CERT audits and investigations to achieve objectives.

CMS has clarified the fact that MACs are responsible for identifying claims that are improper, as well as providers engaged in fraudulent or abusive practices. This concentrated focus on weeding out abuse and fraud is the bottom line when it comes to CERT audits. If you have a practice and you receive notice of an audit, bear in mind that it isn’t necessarily because you have done something wrong. Instead, it’s likely because they are paying much closer attention to what’s happening throughout the system.

The purpose of a CERT audit has always been to find mistakes, and that hasn’t changed. Despite the fact that you are not necessarily being accused of fraud, it’s still imperative that you take the audit seriously and with the highest level of diligence. Although CMS held MACs responsible for widespread payment issues, it’s the health practitioner that will be held responsible in the event that overpayments are found. That’s also who will suffer the consequences. If there are issues, you’ll want to work closely with your legal counsel to develop a strategy for engaging with the proper agencies.

To effectively handle a CERT audit, many organizations bring in a lawyer during the process. The value of working with a qualified attorney is you can lean on their expertise to get through the audit successfully. It’s also important to make sure all of your internal practices align with CMS requirements.

CERT Audit & Investigation Process

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