YOU Impact the National Medicare (CERT) Error Rate

As you should know, the CERT program consists of a random sample of Medicare claims selected each month which undergo an independent medical review process whereby the claims data are adjudicated against the medical records of the physician/provider. The results are analyzed and used to produce annualized estimates of the dollars paid incorrectly for each of the 15 Medicare Jurisdictions as well as Medicare nationally. This is done by statistically extrapolating the findings from the sample to the entire universe of Medicare claims. These estimates take in to account both underpayments and overpayments made by Medicare. What you may not realize is the relative importance of each CERT claim given that each one is extrapolated during the estimation process mentioned above. Because of the low relative volume of claims in the CERT sample, each claim and dollar reviewed by CERT is extremely important. For example, in Part B, a single CERT error of $100 becomes approximately $3,000,000 in reported error after extrapolation. In Part A, the multiplicative factor used in extrapolating is less drastic, but, since Part A claims are generally much more costly to begin with, they are no less important. For example, a Part A error of just $1,000 would lead to about $5,000,000 in error upon extrapolation. While the individual physician/provider is not responsible for repayment of this extrapolated amount, that entire amount is reflected against the physician/provider’s specialty or facility type when analysis is done by CMS. Furthermore, that entire amount does go into the total dollars-in-error figure which is reported by CERT each year and ultimately reported by the media and government officials anytime they discuss Medicare spending and waste. As a participant in the Medicare program it is critical that you understand the fundamental role that you play in determining these errors – the errors that in turn serve as the foundation for calculating the amount of “waste” in the Medicare program. One of the most important things that you can do to help minimize these errors is to make sure that you date and sign every clinical document that you prepare. This includes physician notes, orders for laboratory services and diagnostic testing, standing orders, care plans, protocols, etc. If you are receiving any of these documents or requests from another physician/provider do not accept it unless it has been signed and dated. If you choose to accept orders or other documents that have not been properly prepared (i.e., signed & dated), then the services you provide are potentially at risk for being non-reimbursable by Medicare.

Unfortunately, at the present time physician documentation and signature issues are the leading cause of CERT errors.



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