The CMS implemented the Comprehensive Error Rate Testing (CERT) program to measure improper payments in the Medicare Fee-for-Service (FFS) program. CERT is designed to comply with the Improper Payments Information Act (IPIA) of 2002, as amended by the Improper Payments Elimination and Recovery Improvement Act (IPERIA) of 2012. The datasets are comprised of information on Medicare fee-for-service (FFS) claims that underwent CERT medical review. These claims were used to calculate the Medicare FFS improper payment rate. A provider can search by Claim Control Number (CCD) and see if their claim was paid or denied.
The objective of the CERT program is to estimate the accuracy of the Medicare FFS program. The CERT process includes 1. Claim Selection 2. Medical Record Requests 3. Review of Claims 4. Assignment of Improper Payment Categories 5. Calculation of the Improper Payment Rate. The CERT Program calculates the paid claims error rate for Medicare claims submitted to Carriers, Durable Medical Equipment Regional Carriers, and Fiscal Intermediaries. The Centers for Medicare and Medicaid Services receives in excess of 2 billion claims per year. CERT randomly selects a statistical sample of these claims for review to determine whether the claims were paid properly. CERT selects a stratified random sample of approximately 40,000 claims submitted to Part A/B Medicare Administrative Contractors (MACs) and Durable Medical Equipment MACs (DMACs) during each reporting period. This sample size allows CMS to calculate a national improper payment rate and contractor- and service-specific improper payment rates. The CERT program ensures a statistically valid random sample; therefore, the improper payment rate calculated from this sample is considered to reflect all claims processed by the Medicare FFS program during the report period. The sample of Medicare FFS claims is reviewed by an independent medical review contractor to determine if they were paid properly under Medicare coverage, coding, and billing rules. If these criteria are not met or the provider fails to submit medical records to support the claim billed, the claim is counted as either a total or partial improper payment and the improper payment may be recouped (for overpayments) or reimbursed (for underpayments). The last step in the process is the calculation of the annual Medicare FFS improper payment rate, which is published in the Health and Human Services (HHS) Agency Financial Report (AFR).