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Watch carefully for Medicare CERT audit notices

February 9, 2012

The AOA Advocacy Group urges optometrists and practice staff members to watch their mail carefully for Medicare CERT audit record requests that will arrive in brown window envelopes, not unlike those used for many more-routine notices or commercial mailings. The AOA Advocacy Group is concerned the record requests may be mistaken for “junk mail” in some practices.

The nation’s four durable medical equipment Medicare administrative contractors (DME-MAC) are cooperating in a new, joint effort to determine error billing rates for durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) as part of the Medicare Comprehensive Error Rate Testing (CERT) Audit Program.

Optometrists are among those who may receive requests for claims documentation under the CERT program, the AOA Advocacy Group notes.

Practitioners should always watch their mail carefully for CERT record requests and respond to any such requests promptly, the AOA Advocacy Group emphasizes.

Failure to respond promptly could result in claim denial and demand for repayment, the CMS warns.

The CERT audit program was implemented by U.S. Centers for Medicare & Medicaid Services (CMS) to determine specific billing error rates for the Medicare fee-for-service program and is designed to help achieve objectives outlined in the federal Improper Payments Elimination and Recovery Act of 2010 (IPERA).

Prior to the CERT program, the government estimated Medicare FFS billing error rates.

The audit program is intended to provide more accurate data including specific error rates for the various types of Medicare payment contractors, individual contractors, health care services, and various categories of providers and practitioners.

The latest round of CERT audits on DMEPOS – including eyeglasses – are being conducted by the recently established CERT Operations Center.

The center is randomly selecting a sample of approximately 50,000 claims submitted to Medicare carriers, fiscal intermediaries, and DME-MACs. 

Auditors will review the claims and associated medical records for compliance with Medicare coverage, coding, and billing rules.

Auditors have been instructed to consider any failure to provide medical records or other required documentation in response to an audit notice as a claim filing error, according to the CMS.

When an error is determined to have resulted in overpayment or underpayment, a payment adjustment will be made and a notice will be sent to health care practitioners or product suppliers, according to the CMS.

Authorized under the federal Improper Payment Information Act of 2002, the CERT audit program is designed to help ensure the financial integrity of the Medicare program by providing error rate data that can be used to improve claim submission, processing, and payment, as well as develop supplier education materials, according to the CMS.

Using results of the audit program, the nation’s four DME MACs will work as a single unit to provide education on DMEPOS claim filing, the agency notes.

“Our primary purpose is to centralize education specific to the CERT program and to present a single educational voice and message to suppliers throughout the United States,” agency officials noted during the November Webinar on the program.

Because the claims are randomly selected, program results cannot be used to establish a pattern of inappropriate billing by a practitioner that could result in an allegation of fraud, the agency emphasized.

However, businesses or health care practitioners who fail to respond to audit requests in a timely fashion will be subject to significant penalties: specifically, retroactive denial of the claim for which documentation has been requested and a demand for repayment, the CMS also emphasizes.

“It’s important for optometrists to understand that if they do not respond, then their payment for the claim will be presumed improper and they will automatically be asked to return the reimbursement for the claim,” AOA Advocacy Group Director Jon Hymes emphasized.

Practitioners should also be aware that the audit notices will be mailed in brown window envelopes, not unlike those used for some other Medicare notices and many commercial mailings, according to Charles B. Brownlow, O.D., AOA medical records consultant.

Dr. Brownlow is concerned that some practitioners or office staff may mistake the audit notices for “junk mail.”

“Optometrists are constantly bombarded with offers and warnings in official-looking envelopes that are bogus,” said Dr. Brownlow.

He urged practitioners to watch carefully for mail from the CMS CERT Operations Center marked “Medicare record request” and “Immediate Response Required.”

Dr. Brownlow recommends optometrists check the return address on envelopes as means of determining if a mailing has actually come from the CMS.

“Checking to see if the return address specifically states that a mailing has come from the CMS can help sort the wheat from the chaff,” Dr. Brownlow said. “Practitioners should pay special attention to everything they receive directly from CMS.”

CERT DMEPOS audit response

Optometrists who receive requests for claims documentation under the CERT program should understand how to respond properly, the AOA Advocacy Group notes.

On receiving a record request as part of the new round of CERT DMEPOS audits, practitioners will be required to provide the specified documentation, along with a cover letter, within 30 days.

Failure to respond will result in the issuance of up to three follow-up request letters at 15-day intervals.

If the CERT DMEPOS Operations Center receives no response from the practitioner following the final letter, the claim referenced in the request will be denied and a demand letter will be issued, according to the CMS.

Responses must include:

  • The physician order for the DMEPOS product cited in the request – in the case of eyeglasses, the prescription.
  • The dispensing order for the product. (The respondent may indicate the order was verbal but must provide the beneficiary’s name, ordering physician’s name, and the date of the order.)
  • Detailed written orders including a description of the item, the physician’s signature (with date), the beneficiary’s name, physician’s name, date of the order, options or additional features, and ICD-9-CM diagnosis codes (as required by policy).

Health care practitioners can respond to the audit requests by faxing or mailing the requested claim documentation according to the instructions provided in the letter.

While the CMS would prefer faxed responses, practitioners can also mail paper copies of the required documentation or images of the documentation on CD-ROM to the CERT Documentation Office at the address provided in the audit notice.

(Practitioners who opt for a CD-ROM should use a special bar-code page, included with that audit notice, as a cover sheet, according to the CMS.) 

Health care practitioners who need additional time to comply with an audit notice can request an extension by calling the CERT Documentation Office at 888-779-7477 or 301-957-2380.

The CERT DMEPOS Documentation Office can be contacted at 240-568-6222.
 (The new CERT DMEPOS Operations Center is coordinating only audits regarding DMEPOS, the AOA Advocacy Group notes. Health care practitioners who receive audit requests regarding health care services should use contact information provided in those requests.)

For additional information, visit CERT page on the CMS Web site (www.cms.gov/CERT).

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