Comprehensive Error Rate Testing Review Contractor

Background
The Centers for Medicare & Medicaid Services (CMS) developed the Comprehensive Error Rate Testing (CERT) program to calculate the Medicare Fee-for-Service (FFS) program improper payment rate. The CERT program considers any claim that was paid or denied when it should have been denied or paid at another amount to be an improper payment. The error is then categorized into one of five major categories: No Documentation, Insufficient Documentation, Medical Necessity, Incorrect Coding, or Other. The CERT program calculates improper payment rates based on the results of the reviews conducted and ensures a statistically valid random sample.

Work Details
The contractor is required to perform various tasks including:
- Selecting a stratified random selection of claims from the Medicare FFS claims universe
- Requesting medical records from billing and ordering providers
- Receiving and processing medical records for conducting medical review
- Providing customer service support to the Medicare Administrative Contractors (MACs) and providers
- Conducting medical review on claims selected for CERT and other accuracy reviews as specified by CMS
- Communicating medical review results to stakeholders
- Collecting and transmitting data to the CERT Statistical Contractor for calculating improper payment rates
- Maintaining various websites for internal and external stakeholders
- Establishing mechanisms to manage unexpected fluctuations in workload
- Performing additional tasks directed by CMS and the Statement of Work.