BC Advantage - 2017 Issue 10

Avoid Denials and Mitigate Risk Under the CMS CERT Program

Insufficient documentation is by far the most common reason for denying a claim or improperly paying a claim. Improperly paid claims become problematic after identification by the Center for Medicare and Medicaid Services (CMS) Comprehensive Error Rate Testing (CERT), a random sampling of claims evaluated for compliance with Medicare coverage, coding and billing rules.  After a claim has been identified by CERT, an initial request for records and documentation is sent to the submitting provider or supplier via a medical record documentation request.  Up to three subsequent requests for information are sent if no additional documentation...

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