The Comprehensive Error Rate Testing (CERT) program is a CMS initiative that seeks to identify national error rates in a variety of areas. Temporarily suspended due to COVID-19, the CERT program came back into action in August 2020.
The program, in a nutshell, seeks to identify areas of weakness where providers’ documentation is lacking, and Medicare winds up paying for services that would otherwise have been denied for a lack of documentation to support the item, service or procedure that was billed to the program.
This past year, the overall error rate was over 6%, resulting in an extrapolated estimated overpayment calculation of over $25 billion. Yes, that was billion. With the Medicare program becoming insolvent in the coming few years, a number as large as that could extend the life of the program.
A solid self-audit program works to establish baseline weaknesses in a practice, affords a provider the opportunity to both maintain and generate revenue, establish an internal program that meets the OIG Model Compliance Guidance, as well as creates a compliant organization as required by the Affordable Care Act (many do not realize that a participating provider in the Medicare program is required to have a compliance plan).
Those intent on committing fraud are not concerned with these areas, and much of the discussion about compliance is ignored by this sector of the healthcare provider community. Errors can be the result of fraud, waste, or abuse. When I was an OIG agent, I do not think I ever once looked at an allegation and thought separately about which bucket it would best fit.
The US Attorney’s Office would typically make that determination when deciding if the case was a criminal or civil matter. In making that decision, those matters where the facts bore out to fraud, were then criminally prosecuted. Everything else would largely be seen as a civil matter.
CERT is an important project, as it works to set overall benchmarks to identify areas where there are program weaknesses (those areas where CMS would need to tighten up policies, or areas where the OIG might look to conduct audits and investigations), while giving providers the opportunity to conduct a self-audit to identify areas where their own weaknesses can be addressed.
The goal of a practice should be, at a minimum, to have internal error rates of below 5%. I use this number, as this percentage will commonly be found in many OIG documents as it pertains to statistical sampling and corporate integrity agreement (CIA) reporting. It is also a common margin of error in statistical sampling.
Great and exciting things are happening at Advize. For those that follow us on LinkedIn, read our newsletter, listen to our podcasts, and humor me in my excessive postings about FWA, you know that we give our all to FWA and compliance work. Our team of subject matter experts in FWA is unmatched; retired law enforcement from the likes of the OIG and the New York City Police Department, qualified experts (generally, very few people have been qualified as an expert to provide the CMS perspective, and we have them!) ready to testify in various court proceedings on CMS policies and perspectives, and our team of data scientists, present great opportunities for us to handle the self-auditing process.
We will be making a HUGE announcement in the very near future about some additional offerings, that will greatly expand how we work with providers, payers, and the legal community in the FWA space. We are committed to bringing our clients only the best.