For Audits, Emphasize Preparation, Not Panic

Now is the time to prepare, assess time frames and provider requirements, and ensure a proper compliance plan is in place.

On March 30, the Centers for Medicare & Medicaid Services (CMS) provided a temporary respite on audit activities due to the COVID-19 crisis. This was undoubtedly a welcomed break, as providers were dealing with unplanned layoffs and the furlough of employees, while at the same time, they were required to suspend nonessential procedures. Understandably, however, this respite could not go on forever, and the resumption of audit activity has been expected.   

Effective Aug. 11, CMS officially resumed the Comprehensive Error Rate Testing (CERT) Hospital Payment Monitoring Program – even though the federally declared public health emergency (PHE) was renewed in late October. As noted on the CMS website for providers, “due to the cyclical nature of the CERT program, improper payment measurement, and the statutory timeline required for improper payment reporting under the Payment Integrity Information Act of 2019 (PIIA) (i.e., reporting annually), improper payment measurements cannot pause for an extended period without missing the statutorily required due dates.”

Timing is Everything
The claim submission time frame is important for healthcare organizations to understand with regard to the restart of the Recovery Audit Contractor (RAC) audit process. The CERT Program will not be looking at RY (reporting year) 2020 as they resume audits. They will start with RY 2021 and RY 2022, as defined on the CMS website: “specifically, the CERT program will send documentation request letters to and conducting phone calls with providers or suppliers to request medical documentation for claims in RY 2021 (claims submitted July 1, 2019 through June 30, 2020) and RY 2022 (claims submitted July 1, 2020 through June 30, 2021).” 

“The CERT program will report the 2020 Medicare Fee-for-Service (FFS) program improper payment rate in the November 2020 Department of Health and Human Service (HHS) Agency Financial Report (AFR), based on the data that CMS currently has or that providers or suppliers voluntarily submit,” the excerpt concludes

The CERT program is one way CMS seeks to improve the quality and accuracy of the submission and payment of Medicare claims. CMS’s goal is to reduce payment errors by identifying and addressing billing errors concerning coverage and coding. The purpose of the CERT program is similar to that of the RAC program; however, RAC looks at providers’ errors, while the CERT program examines errors in carriers’ payments. The agency performs various fee-for-service claim reviews, most through private contractors, to ensure that hospitals, physician clinics, and other healthcare providers weren’t overpaid for services.

The CERT program is of particular concern at present, observing the large volume of changes in recent months, with the added introduction of various codes and guidelines. This year’s pandemic brought about large-scale changes, including a surge of variable coding and billing guidelines. This, combined with unusually high volumes, may result in increased inaccuracies.

Combining the expansive regulatory flexibility given with the associated complexities in coding and billing, the opportunity for inaccurate reporting of services gives way to the capacity for improper billing. Hospitals and other providers may find themselves at an elevated risk level with possible COVID-related claim irregularities. When patterns of incorrectly paid claims appear on CERT’s radar and an error is uncovered, money is taken back from the hospital – and this is certainly not an ideal time for that.

Preparation is Key
Many providers have placed a definitive focus on creating an internal audit plan for coding, billing, and reimbursement, which will help ensure accurate payment to safeguard claims against audits.

CERT compliance review is performed on a sample to ensure that claims complied with Medicare coverage, coding, and billing rules. Proactive measures should be put in place to address issues before a possible audit review. 

If a claim is determined to be paid incorrectly, upon review, this will be scored as errors. Some common errors include insufficient documentation, medical necessity issues, incorrect coding, as well as various billing errors ─ all are issues that can be addressed with practical, proactive actions. Certain considerations, such as the validation of code assignments and supportive documentation, and remediation plans on internal errors discovered, are just some measures that can be taken in preparation. 

Despite audit concessions in recent months, all providers and healthcare facilities are strongly advised to devote proper attention to every overpayment and audit letter received. For inappropriate services or services reported in the wrong amount, any payment to the wrong provider is considered an improper payment by CMS.

Claims processed during and especially at the beginning of the PHE are likely to be subject to multiple rule changes that have incurred frequent variations, increasing the risk of errors.

Avoid hastily and unnecessarily returning any overpayment by validating overpayments before you accept audit findings. It is vital that qualified staff or a third party auditor re-audit records identified as having overpayments. Utilize only experienced staff or the expertise of a third party, if needed, and consider all appropriate regulations and/or payor policies applicable on the date of service.

The PHE and temporary pause in CMS audits further emphasizes an ongoing issue, which is the critical need for healthcare facilities to centralize and consolidate data and operating functions. 

The centralization of processes in regard to internal activities of audits is also key for a successful compliance plan. Centralizing processes will enable streamlined communication, which further reduces operational and financial strains associated with audits.

  • The centralization of processes will harness the required resources.
  • Collaboration among varying departmental teams creates efficiency.
  • Clear communication between payor and provider reduces costly errors.

According to another important note outlined by CMS “providers and suppliers should contact the CERT Documentation Center Customer Service to identify any hardships or additional time needed with responding to a CERT documentation request. CMS will continually evaluate the CERT program activities to gauge whether any future suspension might again become necessary.”

Audits may increase; however, maintaining awareness and careful management of potential risk areas will help mitigate risk and future obstacles.     

The key to compliance in relation to audit preparation is your capacity to remain up to date on coding and documentation requirements, and your confidence in providers’ abilities to substantiate clinical documentation to support service rendered. All inquiries must be addressed immediately to ensure adequate time for review, and take action on any needed steps. 

As CERT programs resume, maintaining a balance of awareness, preparation, and responsiveness will help to minimize potential cash-flow interruptions.


Susan Gatehouse, RHIT, CCS,CPC, AHIMA-Approved ICD-10-CM/PCS Trainer

Susan Gatehouse is the founder and chief executive officer of Axea Solutions. An industry expert in revenue cycle management, Gatehouse established Axea Solutions in 1998, and currently partners with healthcare organizations across the nation, to craft solutions for unique challenges in the dynamic world of healthcare reimbursement and data management.

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