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Other Review Entities

Type of Review Contractor Brief Description 
Comprehensive Error Rate Testing (CERT) AdvanceMed The CERT was established by CMS to monitor and report the accuracy of Medicare Fee-For-Service (FFS) payments. The CERT program calculates the paid claims error rate for Medicare claims submitted to Part A, Part B and DME Medicare Administrative Contractors.
Recovery Audit Contractor Health Data Insights (HDI) The Recovery Auditor detects and corrects past improper payments so that CMS, claims processing contractors, and suppliers can implement actions that will prevent future improper payments.
Office of Inspector General (OIG) OIG The OIG protects the integrity of Department of Health and Human Services (HHS) programs, as well as the health and welfare of the beneficiaries of those programs. The OIG has a responsibility to report both to the Secretary and to the Congress program and management problems and recommendations to correct them. The OIG's duties are carried out through a nationwide network of audits, investigations, inspections and other mission-related functions performed by OIG components. (Public Law 95-452 (as amended))
ZPIC Safeguard Services (SGS) The primary goal of ZPICs is to investigate instances of suspected fraud, waste, and abuse. ZPICs develop investigations early, and in a timely manner, take immediate action to ensure that Medicare Trust Fund monies are not inappropriately paid. They also identify any improper payments that are to be recouped by the MAC.
Quality Improvement Organization (QIO)

State-specific Contractors

The QIO program protects beneficiaries by expeditiously addressing individual complaints, such as beneficiary complaints; provider-based notice appeals; violations of the Emergency Medical Treatment and Labor Act (EMTALA); and other related responsibilities as articulated in QIO-related law.

Supplemental Medical Review Contractor (SMRC) StrategicHealthSolutions, LLC External Website This contractor conducts special Medical Review Studies of Part A and B claims on a quarterly basis and vary in topic. Examples of topics include Inpatient Psychiatric Facility Interrupted Stays, Epidural Injections, and Place-of-Service coding.

 

Determining Who Reviewed Your Claims

Multiple CMS contractors are charged with completing reviews of medical records. This includes the Comprehensive Error Rate Testing (CERT) Contractor, Recovery Auditor (RA) Contractor, and many more. See Identifying Which Entity Completed a Part A Claim Review for detailed information about each of these contractors.

Resources

Last Updated Dec 13, 2016