CERT Contractors Identifying Documentation Errors for Home Health Services

Monday, July 22, 2013
By George F. Indest III, J.D., M.P.A., LL.M., Board Certified by The Florida Bar in Health Law

About a year ago we told you about one of the newest acronyms in the Medicare Program’s audit process, “CERT” which stands for the Medicare Comprehensive Error Rate Testing Program. The CERT Program is one way CMS is trying to improve the quality and accuracy of Medicare claim submissions and payments of those claims. Recently Medicare Contractors have reported seeing an increase in errors identified by the CERT Contractor for home health services, according to the Centers for Medicare and Medicaid Services (CMS). Most of the errors are reportedly due to insufficient documentation in the face-to-face encounter narrative by the certifying physician.

To read more on this issue from CMS, click here.

What is the CERT Program?

CMS created the CERT program to measure the paid claims error rate for Medicare claims submitted to Medicare administrative contractors, carriers, durable medical equipment regional carriers, and fiscal intermediaries (now Medicare Administrative Contractors or MACs). CMS receives more than two billion claims annually. The CERT program randomly selects approximately 120,000 of these claims for review to determine whether the claims were properly paid.

Statistical samples are selected and the CERT documentation contractor (CDC) submits documentation requests to those providers who submitted affected claims. Once the requested documentation has been received, the information is forwarded to the CERT review contractor (CRC) for review. The CRC will review the claims and supporting documentation to measure compliance with Medicare coverage, coding and billing rules. Click here to read a previous blog on the CERT Program.

Medicare Coverage in Home Health Services.

The Medicare home health benefit pays for certain health care services in the home setting if the services are considered reasonable and necessary for the treatment of an illness or injury and certain other criteria are met. There are several documentation elements that must be submitted with a home health service claim to support that the beneficiary was eligible for coverage.

According to CMS, the most common problems being detected in the CERT audit of home health services has to do with documentation in the face-to-face encounter narrative by the physician.

CMS Offers Guidance on Common CERT Program Errors.

CMS does offer guidance. According to a CMS fact sheet on common CERT Program errors, a narrative explanation must include the physician’s description of how the clinical findings as seen during the face-to-face encounter support the beneficiary’s homebound status and need for skilled services. Lists of diagnoses, recent injuries or surgical procedures alone are not sufficient to explain why the findings from the face-to-face encounter support the medical necessity of the services ordered and the beneficiary’s homebound status.

To read the entire CMS fact sheet describing the most common CERT Program errors, click here.

If you or your facility provides home health services it is very important that you follow the CMS guidelines to avoid a CERT audit.

Our Experienced with the CERT Program.

In working with the CERT Program, we have been pleasantly surprised when our personal phone calls to CDC and the CRC have been answered and actual accurate information provided, as well as letters and documents we provided being promptly acknowledged. Like with any other audit, however, we urge those being audited to seek the advice of an experienced health law attorney who may be able to assist in heading off and avoiding a more serious investigation or a large repayment demand eventually resulting.

Don't Wait Until It's Too Late; Consult with a Health Law Attorney Experienced in Medicare and Medicaid Issues Now.

The attorneys of The Health Law Firm represent healthcare providers in Medicare audits, ZPIC audits and RAC audits throughout Florida and across the U.S. They also represent physicians, medical groups, nursing homes, home health agencies, pharmacies, hospitals and other healthcare providers and institutions in Medicare and Medicaid investigations, audits, recovery actions and termination from the Medicare or Medicaid Program.
For more information please visit our website at www.TheHealthLawFirm.com or call (407) 331-6620 or (850) 439-1001.


Have you heard of CERT audits? Has your practice encountered a CERT audit? Please leave any thoughtful comments below.

About the Author: George F. Indest III, J.D., M.P.A., LL.M., is Board Certified by The Florida Bar in Health Law. He is the President and Managing Partner of The Health Law Firm, which has a national practice. Its main office is in the Orlando, Florida, area. www.TheHealthLawFirm.com The Health Law Firm, 1101 Douglas Ave., Altamonte Springs, FL 32714, Phone: (407) 331-6620.

Tag Words: Comprehensive Error Rate Testing (CERT), CERT contractor, cert audits, Medicare, Medicare Comprehensive Error Rate Testing program audit, CERT Program errors, CERT documentation contractor (CDC), CERT review contractor (CRC), home health services, home health service documentation, face-to-face encounter narrative, home health benefits, home health agencies, Medicare, Medicare fraud, Centers for Medicare and Medicaid Services (CMS), Medicare contractors, CERT attorney, CERT lawyer, defense attorney, defense lawyer, The Health Law Firm

"The Health Law Firm" is a registered fictitious business name of George F. Indest III, P.A. - The Health Law Firm, a Florida professional service corporation, since 1999.
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