Article Detail - JE Part B
Comprehensive Error Rate Testing (CERT) Reviews and Clinical Laboratory Claims
What is CERT:
- Created to measure error rate of improper Medicare payments for Fee-For-Service programs.
- CERT contractor - Empower AI
- Goal is reducing improper payment rate measured by CERT program.
- Submit documentation in 45 days.
- Findings sent to MAC to educate providers.
- CMS expectation - Providers and labs and radiology providers work together to get necessary records.
What did their claims reviews find regarding clinical lab claims?
- Laboratory services were frequently denied for missing documentation:
- Missing or incomplete orders
- Documentation missing necessary to support medical necessity or intent.
- Results of tests billed.
- Basic billing requirements such as missing signatures
Make sure your billing staff is sending all required information for CERT reviews to reduce your staff workload.
Resources
- CMS What’s the Comprehensive Error Rate Testing (CERT) Program?
- CMS Medicare Learning Network MLN909221 - Complying with Documentation Requirements for Lab Services
- CMS Internet Only Manual (IOM) Publication 100-02 Medicare Benefit Policy Manual Chapter 15 Section 80.6
- Physician’s Orders for Diagnostic Laboratory Tests
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