In an effort to improve the processing and medical decision making involved with the payment of Medicare claims, the Centers for Medicare & Medicaid Services (CMS) began a program in August 2000 to achieve the goals of the Government Performance Results Act of 1993. This act sets performance measurements for Federal agencies. The Comprehensive Error Rate Testing (CERT) program assesses the success of our work as a Medicare contractor to reimburse providers correctly while protecting the Medicare Trust Fund. The CERT program will produce national and contractor specific error rates that will be posted on the CMS Web site in the future.
AdvanceMed, the CERT contractor, will select a random sample of approximately 200 claims processed by each Medicare contractor each month. When one or more of a Medicare provider's claims are selected for the sample, that provider will receive a request from AdvanceMed for additional information that may include medical records, certificates of medical necessity, etc. This information must be submitted to AdvanceMed within 45 days of the request. AdvanceMed s clinical staff, consisting of nurses, physicians, and other qualified healthcare professionals, will review the claims and verify that the contractors decisions regarding the processing of the selected claims were accurate. Failure to respond to this request for documentation will result in a request for overpayment of the services selected for audit.
For more information, please visit the CMS Web site at http://www.cms.hhs.gov or Palmetto GBA s Web site, http://www.PalmettoGBA.com.