CERT Changes 

What is CERT?

The Comprehensive Error Rate Testing Program (CERT) is the Centers for Medicare and Medicaid (CMS) contract process to monitor the accuracy of claims filed and payments made by the Medicare contractors. The method by which this is done involves a CERT review contractor(PSC) requesting and reviewing medical record documentation.

What are the changes?

The CERT program has recently changed their time frames for responses to notification. Prior to 11-06, providers had 90 days to return requested information. The time frame is now 60 days for an OIG letter to be generated and 75 days for the claim to be scored an error.

Why is important to respond in time?

If the information requested is not received in time, the carrier will automatically recoup from the provider the money paid for the claims.  

Where are these notices sent?

The original notice is supposed to be sent to the “pay to” address that was on the provider’s original Medicare application. If they do not get a response, they will send a notice to the provider’s practice address, which for hospital based providers is the hospital. Unfortunately, the hospital mail departments are not always good about getting mail to the physicians. It is important for providers to check any mail slots, files, etc. on a regular basis. 

If you receive a CERT letter at your home or at the hospital, it is important that you get a copy to your billing agent immediately so that an appropriate and timely response can be made. 

What is the process MedaPhase has put in place to handle these requests?

In addition to providing all of the medical record information requested for a CERT audit, Medaphase has all records audited by a coding supervisor. The audit record is included along with an analysis of cogent record contents in regard to the codes that were assigned. If it is required, the MedaPhase Medical Director includes additional clinical information that can help clarify physician documentation that may not be easily understood by an auditor.  

Medicare Provider Enrollment – Issues potentially impact all providers - This could mean YOU!  

What are the issues?

• NPI implementation – In preparation for the National Provider Identifier, Medicare contractors such as Trailblazer have been overwhelmed with testing for claims submission using NPI and matching and entering provider information into the PECOS database. All providers must have their NPI and use it for submitting claims by May 23, 2007.
• New Provider Enrollment – Due to problems with entering information into the PECOS system, staffing issues, etc., Medicare contractors are having significant delays in assigning Medicare Provider numbers. Time lags are typically over 100 days and often longer. Then, due to computer and staffing issues, even after numbers have been assigned it often takes 30+ days to get the numbers to the providers. This is especially problematic in Texas where electronic submission capabilities (EDI) and Medicaid applications both require Medicare number documentation prior to submission. 
• Revalidation - Previously enrolled providers will soon begin to receive notices confirming their current status at a hospital or with a group and requiring them to “re-enroll” in the Medicare program. These notices are very important as a non-response could cause Medicare to terminate the provider number and payment for services. Medicare will not pay for any services rendered during the interim while the new application is being processed (see time frames above for processing applications) It is CMS’s intention to have all physicians enrolled in the PECOS system some time in the future. 

Who is affected?

While this issue primarily affects physicians new to a practice or hospital, the NPI issue impacts all providers, and requests for revalidation and/or re-enrollment could impact any provider.  

What should you do?

Please watch for any notices from Medicare, Trailblazer, or any other Medicare carriers and make sure they are forwarded to MedaPhase immediately for processing. It is imperative that physicians monitor their mail slots or files at the facilities so that important messages are conveyed in a timely manner.