Other Medicare Audits

Medicare Administrative Contractors (MACs)
Comprehensive Error Rate Testing Programs (CERTs)
Quality Improvement Organizations (QIOs)

Medicare Administrative Contractors (MACs)

In addition to the RACs, providers also will continue to be the target of audits from Medicare Administrative Contractors (MACs). CMS is currently in the process of transitioning and consolidating the role of intermediaries and carriers into MACs, who will handle the processing and administration of both Part A and Part B claims.

One of CMS’s stated goals is to simplify provider services by having a single MAC process for both Part A and Part B claims. Further, CMS expects the competitive bidding process to encourage MACs to deliver better service to providers. CMS awarded a total of 19 MAC contracts through the competitive bidding process, and the MACs must re-compete for the contracts every five years.

The MACs participate in the medical review program, which is geared toward reducing claims error rates by addressing billing errors involving coverage and coding vulnerabilities. The MACs first identify potential problems through data analysis and then conduct probe audits on select providers. Contractors review submitted claims to determine proper payment amounts and adjust or deny payments if the services are found not to be reasonable or medically necessary, or if the claims submitted do not properly reflect the services furnished. If the percentage of claims containing errors is sufficiently high, contractors may subject providers to additional post-payment review, pre-payment review, or suspension of payments.

Comprehensive Error Rate Testing Program (CERTs)

The Comprehensive Error Rate Testing (CERT) program is designed to determine the underlying reasons for claim errors and to develop action plans to improve compliance with payment, claims processing, and provider billing requirements. CMS has contracted with Livanta to serve as the CERT Documentation contractor and AdvanceMed to serve as the CERT Review contractor. Specifically, the CERT program is used to establish an error rate for all provider claims other than inpatient acute hospital claims.

The CERT contractor reviews approximately 120,000 claims processed by the affiliated contractors each year. The CERT contractor randomly selects a sample of Medicare fee-for-service (FFS) claims and requests medical records and supporting information from the providers who submitted the claims. In reviewing the sampled claims and medical records, the CERT contractor follows Medicare coverage decisions, NCDs , coverage provisions in interpretative manuals, LCDs and contractor articles. If written policies are not available, the CERT medical review specialists make determinations based upon their clinical expertise.

The results of the CERT reviews are published in an annual report. Even though the main focus of the CERT is to obtain a general error rate rather than to identify underpayments or overpayments of a single provider or entity, the CERT sends information on both overpayments and underpayments to the carrier or MAC. The MAC then recovers overpayments or pays underpayments in accordance with the same manual instructions normally used for processing such overpayments or underpayments. The affiliated contractor or MAC is responsible for processing appeals stemming from a CERT-initialed denial.

Quality Improvement Organizations (QIOs)

QIOs, previously referred to as peer review organizations ,are charged with reviewing medical services provided to Medicare beneficiaries. QIO’s stated mission is to improve the effectiveness, efficiency, economy and quality of medical care. The core functions of QIOs are to:

• Improve quality of care for beneficiaries;
• Protect the integrity of the Medicare Trust Fund by ensuring that Medicare pays for services that are reasonable and necessary and that are provided in the most appropriate setting; and
• Protect beneficiaries by expeditiously addressing individual complaints, violations of Emergency Medical Treatment and Labor Act and other related responsibilities as articulated in QIO-related law.

CMS contracts with one organization in each state, as well as the District of Columbia, Puerto Rico and the Virgin Islands, to operate as the jurisdiction’s QIO.

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