Comprehensive Error Rate Testing

The CERT program measures improper payments in the Medicare fee-for-service (FFS) program.  CERT is designed to comply with the Improper Payments Elimination and Recover Act of 2010.  CERT randomly selects a sample of approximately 50,000 claims submitted to Carriers, FIs, and MACs during each reporting period.  It requests medical records from health care providers that submitted the claims in the sample, then reviews the claims to see if they complied with Medicare coverage, coding, and billing rules, and if not, assigning errors to the claims.  Where medical records were not submitted by the provider, classifying the case as a no documentation claim and counting it as an error as well as sending providers overpayment letters/notices or making adjustments for claims that were overpaid or underpaid.  The CERT program cannot be considered a measure of fraud since it uses random samples and does not label a claim fraudulent.