Medicare CERT Audit

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Brian Kuester
Attorney Brian Kuester
Medicare CERT Audit Team Lead
Former US Attorney
Former District Attorney
Ellen Comley
Attorney Ellen Comley
Defense Team Lead
Senior Counsel
Roger Bach
Roger Bach
Team Consultant
Former Special Agent (OIG)

For healthcare providers who accept Medicare, a CERT audit is a frequent, though inconvenient, part of doing business. If the audit uncovers mistakes or if the provider does not respond promptly, it can lead to burdensome payment adjustments and the potential for further scrutiny.

Healthcare providers who are being audited should seriously consider hiring a Medicare fraud lawyer to guide them through the process. This can ensure that the audit goes smoothly and, if the audit does find something suspicious, the groundwork is laid for an effective appeal. Providers who are not currently being audited should still consider retaining a lawyer with experience in healthcare fraud to help them create a compliance plan that prepares them for an inevitable CERT audit in the future.

The Medicare fraud lawyers at The Criminal Defense Firm can help on both the defense and the compliance fronts.

How CERT Audits Work

When a healthcare provider, like a hospital or clinic, cares for a patient on Medicare, it sends the bill to a Medicare Administrative Contractor, or MAC. MACs are private healthcare insurers that process claims for Medicare fee-for-service (FFS) payments.

The Comprehensive Error Rate Testing (CERT) program monitors the accuracy of the bills sent by healthcare providers to their MAC. It does this to find potential healthcare fraud as well as wasted dollars and inefficiencies in the FFS system.

This monitoring comes in the form of a CERT audit of healthcare providers.

Every year, the CERT program audits a statistically meaningful sample of FFS claims – often around 50,000 of them per year. These claims include random samples from:

  • Hospital Inpatient Prospective Payment System (IPPS) claims
  • Part A Medicare Providers outside of the IPPS
  • Medicare Part B Providers
  • Claims for durable medical equipment, prosthetics, orthotics, and other medical supplies

The CERT Contractor that is performing the audit contacts the healthcare provider who cared for the Medicare patient and made the claim against the government program through the MAC. The Contractor requests the medical records from the healthcare provider that would support the Medicare claim.

Healthcare providers have 75 days to provide these records. Failing to provide them can lead to the audit flagging the claim as improperly paid. Providers should make absolutely sure to hand over the records on time.

Once the records are received, the audit consists of comparing the patient’s medical records against the Medicare claim. The audit aims to ensure that the Medicare claim was properly paid or denied. It looks at whether:

  • The procedure provided is the one that was billed
  • The care was covered by Medicare
  • The care was medically necessary
  • There is documentation supporting the claim
  • The bill follows Medicare’s coding and billing rules

This review is performed by medical professionals employed by the CERT Contractor, like:

  • Doctors
  • Nurses
  • Certified medical coders

Anomalies and mistakes are flagged as errors. Potential errors are:

  • There is insufficient documentation for determining whether the care was payable through Medicare
  • The care was medically unnecessary
  • The billing code is incorrect
  • There is no documentation for the care provided, at all

These errors are then reported to the MAC that processed the Medicare claim and paid out Medicare money to the provider. The MAC then either covers any underpayments to the healthcare provider or sends a bill to recoup overpayments.

The Appeals Process

Healthcare providers can appeal the outcome of a CERT audit by filing a request for redetermination with their MAC. This request has to be filed within 30 days if the healthcare provider wants to stop the MAC from taking its money back, either by withholding future payments or recouping the amount from current Medicare payments. The provider’s request has to be filed within 120 days of receiving notice of the initial determination, at the latest.

Providers who are dissatisfied with their MAC’s redetermination can request a reconsideration by a Qualified Independent Contractor. This request has to be made within 180 days of the redetermination decision, or within 60 days to stop the MAC from recouping payment.

Providers who are still dissatisfied can take their case to an administrative law judge, the Medicare Appeals Council, and even to a federal district court.

Penalties for Errors

If the CERT audit finds errors in the healthcare provider’s Medicare bills, the repercussions can be widespread.

Financially, the healthcare provider will have to pay their MAC any overcharges that were found in the audit. These payments can be substantial.

Healthcare providers who make a lot of recent errors or who have a long record of billing errors can face sanctions from their MAC. These sanctions are generally in the discretion of the MAC. It can require prepayment reviews of all Medicare claims from the provider in the future, or may even suspend the provider from the program.

If the audit uncovers evidence of healthcare fraud, the evidence may be passed on to other government agencies for further investigation. In the worst case scenario, this can lead to criminal charges being filed against the healthcare provider.

Strict Compliance Can Make CERT Audits Go Smoothly

Because errors carry the potential for significant headaches, lost revenue, restitution payments, and even criminal charges, healthcare providers should strongly consider investing in strict compliance procedures to ensure the audit does not find anything wrong. By implementing a compliance system and making sure that workers stick to it, healthcare providers can turn a CERT audit from being a cause for concern to merely more paperwork.

Frequently Asked Questions

Does an Audit Mean I Am Under Investigation?

No, getting targeted for a CERT audit does not mean that you are under investigation. It just means that one of the claims for reimbursement from the Medicare program that you sent to your MAC has been randomly selected for review. This is simply bad luck, not a cause for concern.

Even if the CERT audit uncovers an error, it does not mean that the healthcare provider is conducting fraudulent activity. It merely means that a mistake was found. The limits of the CERT program make it unable to label a billing practice as fraudulent. However, the errors that it does uncover can turn into evidence of potential fraud. This can lead to an investigation.

Who Performs a CERT Audit?

The CERT program is run by the Centers for Medicare and Medicaid Services (CMS). However, the CMS uses private companies to perform and administer the actual CERT audits. Information on the current CERT Contractors is hosted on the CMS website.

Are CERT Audits Still Suspended for COVID?

No. The Centers for Medicare and Medicaid Services (CMS) put CERT audits on temporary hold in the early days of the coronavirus. That suspension has since been rescinded. CERT audits have resumed, starting on August 11, 2020. However, CMS reduced the sample sizes for the audits for the 2021 and 2022 reports.

Why Doesn’t The Criminal Defense Firm Call Itself the Best Healthcare Defense Law Firm?

Lawyers and law firms are heavily regulated in how they advertise themselves. Ethical rules cover nearly every aspect of legal marketing, including when a lawyer or firm can lay claim to a specialty in a field of law.

But we would rather have our track record of success do the talking for us, anyway. Our attorneys have helped countless clients and healthcare providers defend against serious allegations of fraud, misconduct, and negligent mistakes. Those cases have carried the potential for millions of dollars in damages and even significant amounts of jail time. With legal representation from The Criminal Defense Firm, many of these clients have walked away from precarious legal situations with little to no repercussions. Many of them have even seen their cases get dismissed because of our vigorous defense.

Equally important, many of our clients have retained The Criminal Defense Firm to put workplace compliance codes in place so these allegations of wrongdoing never get made, in the first place. By getting our attorneys involved before legal problems arise, you can invest in a future where they never do.

Healthcare Fraud Lawyers Can Help

By itself, a CERT audit should be nothing more than a hassle. However, it carries the potential for some serious problems if the audit uncovers an error in the claim that was randomly chosen for review. This is why it is generally a wise move to enlist a skilled healthcare lawyer to guide your company through the process.

Whether your healthcare company has been notified of a pending CERT audit or you want to establish compliance measures to prepare for one, the lawyers at The Criminal Defense Firm can help. Contact them online or call their law office at 866-603-4540.

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Nationwide 866-603-4540