Medicare & Medicaid Reimbursement

P. (405) 553-1173 | F. (405) 553-1119

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During a site visit, Valir’s Medicare professionals review medical records for information that supports the services documented on the MDS under RUG-IV reimbursement rules.  Through the retrospective review, Medicare compliance is determined and corrected measures are implemented. The results have been positive and increased revenue has ranged from $12,500 to $245,000 per month.

Site visits include:

  • Medicaid Casemix Audits
  • Medicare Part A Coverage
  • PPS MDS Assessments
  • MDS 3.0 Training

Compliance Consulting: What is a CERT Audit?
The “Comprehensive Error Rate Testing” (CERT) program was created as a tool for the Centers for Medicare and Medicaid Services (CMS) to assess whether Medicare Administrative Contractors (MACs) are paying claims properly.  Essentially, the CERT audit serves as an integral management tool for CMS as well as an important feedback mechanism for the MACs. When problem areas are identified, they can be addressed by Medicare contractors with audit responsibilities.  Notably, several of the MACs around the country have been aggressively reasserting their program integrity roles.

Essentially, MACs write reimbursement checks on behalf of CMS.  As a result, they play a central role in the Medicare reimbursement process. Therefore, when a CERT auditor finds that a MAC has been incorrectly reimbursing providers for claims which may not qualify for coverage, it is very important that the MAC immediately address this system-wide deficiency.  In response to certain CERT audit findings, according to Liles Parker, attorney, one MAC recently sent notification to providers of Evaluation and Management (E/M) services explaining that new “stringent corrective actions” will be taken to address some of the more common claims errors identified by the CERT auditors when conducting their reviews of MAC payment practices. As recent correspondence to a provider reflects, MACs are taking the results of CERT audits quite seriously, and are expanding their program integrity efforts.  As one MAC recently wrote, the contractor stands ready to:

  • Suspend a provider if that provider has “too many” payment errors (it does not state how many is “too many”);
  • Refer every physician to that region’s ZPIC if those providers continue to bill for services which may constitute payment errors;
  • Refer every physician to the ZPIC if there is a pattern of past payment errors; and,
  • Conduct prepayment reviews of future claims, up to 100% of a provider’s claims.

To be clear, none of these potential corrective actions represent new authorities. Nevertheless, the fact that MACs are now reasserting these points is reflective of CMS ongoing concerns regarding the prevalence of improper claims. Indirectly, CMS is making it crystal clear that as the initial recipient and screener of Medicare claims submitted by providers for payment, MACs play an essential role in screening out improper claims and bad providers.  As Medicare’s primary gatekeepers, MACs are responsible for identifying both improper claims and providers who may be engaged in abusive and / or fraudulent practices.

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