Coding Cues: A CERT audit

March 7, 2008

Recently our hospital underwent a Comprehensive Error Rate Testing audit. I have since been notified that because there were no records found for 25 percent of my billed visits, I owe Medicare an enormous amount of money. I have no control over how the hospital manages its records or which ones were requested and produced. Does CMS have the authority to do this and, if so, what should I do?

Recently our hospital underwent a Comprehensive Error Rate Testing (CERT) audit, in which a CMS reviewer audited inpatient records, including some of mine. I have since been notified that because there were no records found for 25 percent of my billed visits, I owe Medicare an enormous amount of money. I have no control over how the hospital manages its records or which ones were requested and produced. Does CMS have the authority to do this and, if so, what should I do?

The CERT program produces national, contractor-specific, and service-specific error rates for paid claims, as well as a provider compliance error rate-a measure of the extent to which providers are submitting claims correctly. The program uses audit contractors to review representative random samples of both paid and denied Medicare claims to check for accuracy. So, yes, CMS can use the findings to bill individual physicians.

What should you do? First and foremost, acknowledge the communication from CMS by the "reply by" date. Then, if you intend to dispute the findings, immediately engage the services of a healthcare attorney who specializes in such cases. There are many reasons that hospitals' medical records departments don't provide all the records requested. The charts may be hard to locate or difficult to access, possibly because they've been converted from paper to electronic records or sent to off-site storage.

Finally, keep the CMS representative who signed the notice you received apprised of the path you're pursuing. If you can prove that the missing records do, in fact, exist and that the documentation supports the level of care you billed for, you should be able to resolve the overpayment charges.