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.


Last Updated Feb 22 , 2024