RISKY BUSINESS?
T
here are several types of Medicare
contractors with the responsibility
of auditing records, claims, and
payments. Each type of contractor may
use different methods to conduct audits,
but they must all abide by overarching
Medicare guidelines for medical review,
denials, appeals, and payment recovery, as
set forth by the Centers for Medicare and
claim payment in the Medicare Fee-For-
Service (FFS) Program. The intent of the
CERT program is to protect the Medicare
Trust Fund by identifying errors and
assessing error rates, at both the national
and regional levels. Findings from the
CERT program are used to identify trends
that are driving the errors, such as errors
by a specific provider type or service and
"MOST ORGANIZATIONS THAT RECEIVE AUDITS
ON A REOCCURRING BASIS ARE MORE THAN LIKELY
BEING TARGETED FOR NONCOMPLIANCE OR
BECAUSE OF PREVIOUS ISSUES. "
MEDICARE ADMINISTRATIVE
CONTRACTORS (MAC)
The MAC deals with minor or isolated
billing issues through provider
notification or feedback with reevaluation
after notification. For serious problems,
the MAC has the authority to review
claims on a prepayment basis. Usually
at the MAC level of review, it is still a
“mistake” vs “fraud”. MACs do have the
authority to do prepayment and reviews,
which are always more difficult for the
provider.
COMPREHENSIVE ERROR RATE TESTING
(CERT)
The (CERT) program was established by
the Centers for Medicare & Medicaid
Services (CMS) to monitor the accuracy of
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assist with allocation of future program
integrity resources. The CERT error
rate is also used by CMS to evaluate the
performance of Medicare contractors, like
CGS.
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Medicaid Services (CMS). Below are the
contractors you may see a request from.