CMS CERT Audits Reveal 11% Improper Payment Rates for 2016

We may be making progress in coding and documentation, but according to the CMS report for 2016 CERT results, a national error rate of 11% is in place, resulting in over $41 billion in improper payments for Part A, Part B, DME and inpatient services.  Notably, this is down from 12.09% in 2015.  CERT audits categorize their review findings into one of the following areas of erroneous payments:

  1. No Documentation
  2. Insufficient Documentation
  3. Medical Necessity
  4. Incorrect Coding
  5. Other

CERT audits focus on the quality of Medicare Administrative Contractors to follow the rules for proper adjudication of claims and payments from the Medicare trust fund.  In their review of MACs, they require documentation from providers and facilities to substantiate the MAC’s payment.  This, in turn, results in a review of the provider as well, although the initial objective of CERT is MAC compliance, not provider compliance.

Coding need not be the focus of a provider’s mission.  Their focus should be on quality of patient care and the fair and accurate reimbursement from payers for the services rendered.  Documentation supports coding and coding supports payment, therefore, accurate and thorough documentation is the core of compliant reimbursement.  MediQuick believes that a provider can become compliant in documentation and coding with a training program that focuses on their deficiencies and corrective action.  Once trained, the provider can be relieved of the concerns in correct coding and redirect their focus to their first love, patient care.  For more information on our provider training options, please contact us.  You can also learn more about the CMS CERT program by clicking here.