DME MAC Program Manager Update - Comprehensive Error Rate Testing (CERT) Program Tips - JA DME
DME MAC Program Manager Update - Comprehensive Error Rate Testing (CERT) Program Tips
In previous articles, we share how CGS and Noridian Program Managers oversee a variety of operational and collaborative workgroups that meet monthly to discuss opportunities for DME MAC process improvements across all four DME MAC jurisdictions.
In this article, the Program Managers want to share the most common reasons why a claim is denied by the CERT Contractor, and to provide you with educational resources for the CERT program.
The CERT contractor is responsible for auditing a sample of each DME MACs claims. The CERT contractor will request that the supplier provide additional documentation for each claim audited. Review of the additional documentation received will determine if the claim is in error or not.
Below are tips for responding to additional documentation requests by the CERT.
- Proof of Delivery of Shipped Items
- Include both the supplier's detailed shipping service invoice and the delivery services' tracking information.
- Show a clear link of your record to the delivery service record.
- Ordering Practitioner's National Provider Identifier
- Make sure the NPI information you provide on the claim matches the name of the practitioner on the order.
- Insufficient Documentation
- Make sure all records are legible.
- Get all the information Medicare needs from the beneficiary during the intake process.
- Be sure your documentation meets all the requirements for the item billed.
- Incorrect Coding
- Be sure the documentation provided supports the code and number of services billed.
- Be sure the correct modifier is used if needed for the code billed.
- Be sure the date of service billed matches the date of delivery.
Use the above tips to avoid an overpayment. Send the additional documentation requested by the CERT promptly. Please use the bar-coded sheet provided by CERT as your cover letter when provided documentation.
To support our DMEPOS suppliers, the DME MACs also collaborate with the A/B MACs to produce educational webinars with a special focus on supporting the reduction in the Medicare Fee for Service error rate. This workgroup presents four webinars each year focused on prescribing practitioner documentation requirements for DMEPOS claims. In 2024, the webinar topics were:
- Documentation requirements for ordering clinicians
- Positive Airway Pressure (PAP)
- Nebulizers
- Lower Limb Orthoses
We collaborate with the A/B MACs to educate providers of services because we know proper payment of your DMEPOS claims depends on the orders and medical records from service providers. The DME MACs will continue to collaborate with the A/B MACs in 2025 in lowering the national DMEPOS CERT error rate.
Our education efforts have helped steadily reduce the DME national CERT errors for the past 5 years. The 2024 DME national CERT error rate is at an all-time low of 21.4%. The DME MACs will continue to collaborate and provide education to continue the positive trend in reducing the national error rate.
Finally, the DME MACs have many CERT educational resources on our websites:
