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Reimbursement Page By Joseph McTernan, AOPA government affairs department
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Seamless CERT Audits > What you don’t know can hurt you
CERT
ZPIC
RAC
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O&P Almanac MARCH 2013
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o say the reimbursement environment facing orthotic and prosthetic providers is a challenging one is an understatement. In the past 18 months, the number of Medicare audits has increased exponentially, creating tremendous pressures on businesses to maintain positive cash flow while ensuring the best possible clinical care for their patients. It is no longer the status quo to expect to be reimbursed for services that are clearly medically necessary without multiple challenges from a federally funded program that is under tremendous pressure to control costs and curb fraud and abuse. The layers of potential audits have become a virtual alphabet soup of acronyms, with terms such as RAC, ZPIC, and CERT becoming all too familiar in the everyday operation of an O&P practice. This month’s Reimbursement Page focuses on one particular type of Medicare audit that often is overlooked: the Comprehensive Error Rate Testing, or CERT, audit. The belief that CERT audits are any less important or have a lesser impact on your operations than other types of audits could not be further from the truth. Downplaying the significance of CERT audits may lead to disastrous consequences.
Understand the History The CERT audit program began with the passage of the Improper Payments Information Act of 2002 and has been strengthened over the years through the passage of additional legislation and the release of several executive orders. Prior to the passage of the 2002 legislation, the Office of Inspector General (OIG) for the Department of Health and Human Services calculated a single National Claims Payment Error Rate that was used to determine what efforts were needed to ensure Medicare was only paying for services that were medically necessary and reasonable. With the passage of the legislation, responsibility for calculating payment error rates shifted to the Centers for Medicare and Medicaid Services (CMS). CMS began calculating multiple error rates both nationally and by categories—including by contractor, by service, and by provider type. Calculating multiple error rates provided data that CMS and OIG could then use to further focus efforts to control fraud and abuse within the Medicare program. The central difference between CERT audits and other types of Medicare audits is that the primary