CERT Medical Necessity Errors

The Centers for Medicare & Medicaid Services (CMS) designed the Comprehensive Error Rate Testing (CERT) program to determine a national paid claims error rate through review of a random sample of paid claims processed by Medicare Contractors. In the last six months, the number of medical necessity errors received by WPS Medicare as a result of CERT claim reviews has almost tripled.

The increase in the number of medically unnecessary claims directly correlates with the updates to regulations in the Internet-Only Manual (IOM) Pub. 100-02, "Medicare Benefit Policy Manual," Chapter 15 (Covered Medical and Other Health Services), Section 80 (Requirements for Diagnostic X-Ray, Diagnostic Laboratory, and Other Diagnostic Tests), Subsection 80.6.1 (Definitions). These changes were identified in Change Request (CR) 6100, implemented on September 30, 2008.

The Medicare Learning Network (MLN) Article MM6100 states that while a physician order is not required to be signed, the physician must clearly document in the medical record his or her intent that the tests be performed. Therefore, it is advisable that the facility keep all copies of paper or telephone orders in the beneficiary’s record as support to ensure that your facility is paid for services provided. If an order is unsigned and it is necessary to obtain evidence of medical necessity please provide the full name and phone number of the provider who ordered the services.

Page Last Updated: Friday, 06-Nov-2009 14:04:44 CST